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

Effectiveness of a nurse-led one-to-one education programme in addition to standard care in children with atopic dermatitis: a multicentre randomized control trial

BACKGROUND

Therapeutic patient education (TPE) is recommended for children with atopic dermatitis (AD), but no consensus has been reached on the optimal tailoring of delivery. While repeated multidisciplinary group education sessions have shown effectiveness, the benefits of one-on-one educational interventions led by nurses for children with AD have not yet been assessed.

OBJECTIVES

To assess the benefits of additional, well-structured, 1-h nurse-led individual TPE interventions in children with AD and their families compared with standard care alone.

METHODS

Children with moderate-to-severe AD and their parents were randomized to receive a 1-h nurse-led education session in addition to standard care vs. standard care alone. The primary outcome was the area under the curve (AUC) of the SCORing of Atopic Dermatitis index (SCORAD) from baseline to week 24 (lower AUC values represent better long-term control of the disease).

RESULTS

In our study, 176 patients were randomized across 11 centres, and 153 were included in the full analysis set. The mean (SD) age was 4.47 (4.57) years. By week 24, there were no significant differences in the AUCs of the SCORAD between the two groups (P = 0.3). Secondary outcomes including patient-reported severity and quality of life [AUCs of the patient-oriented SCORAD (PO-SCORAD) and Infants' Dermatitis Quality of Life Index (IDLQI), Children's Dermatitis Quality of Life Index (CDLQI) and Family Dermatitis Quality of Life Index (FDLQI)] were not significantly different between the two groups. The only significant change observed in the intervention group, when compared with the one receiving standard care, was a decrease in topical steroid phobia, as assessed by the topical corticosteroid phobia (TOPICOP) score. Prespecified subgroup analyses showed that disease severity in the intervention group was significantly lower throughout the study, compared with the standard-care group when participants had moderate AD at baseline (n = 47); while participants with severe AD at baseline (n = 106) did not show benefit from the intervention. Participants showed no additional benefit from the intervention regardless of age group.

CONCLUSIONS

This study did not show any additional effectiveness, in long-term severity control, of a 1-h nurse-led TPE intervention in children with AD treated with standard care, compared with those treated with standard care alone. However, it should be noted that the intervention reduced the fear of using topical steroids and may be beneficial for patients in the subgroup with moderate AD.

Health literacy and asthma: An update

The US Department of Health and Human Services has defined health literacy (HL) as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Structural and social determinants of health lead to low HL in approximately 36% of adults in the United States, where this condition is most prevalent in racial and ethnic minorities, economically disadvantaged communities, and immigrants with limited English proficiency. In turn, low HL can worsen asthma outcomes through direct effects (eg, nonadherence to or incorrect use of medications) and indirect effects (eg, an unhealthy diet leading to obesity, a risk factor for asthma morbidity). The purpose of this update is to examine evidence from studies on low HL and health and asthma outcomes published in the last 12 years, identify approaches to improve HL and reduce health disparities in asthma, and discuss future directions for research in this area under the conceptual framework of a socioecological model that illustrates the multifactorial and interconnected complexity of this public health issue at different levels.

Development and psychometric evaluation of the asthma Action plan questionnaire (AAPQ)

OBJECTIVE

To develop a practical and psychometrically sound tool to evaluate caregiver knowledge of their child's asthma action plan (AAP).

METHODS

A pilot study was conducted in a sample of 40 caregivers of children with asthma to assess the content validity, item difficulty, and item discrimination of the Asthma Action Plan Questionnaire (AAPQ). The inter-rater and intra-rater agreement of the AAPQ's scoring rubric were also examined. Subsequently, a large-scale study was conducted in a sample of 80 caregivers of children with asthma and 40 caregivers of children without current asthma and no prior exposure to patients with asthma to evaluate the internal consistency, test-retest reliability, and known-groups validity of the AAPQ.

RESULTS

The 7-item AAPQ demonstrated acceptable content validity (a scale-content validity index of 0.98) and internal consistency (Cronbach's alpha =.63 and mean inter-item correlation coefficient of.20) and very strong test-retest reliability over a two-to-four-week period (r = .88, p < .001). The AAPQ discriminated between caregivers of children with asthma and caregivers of children without asthma (M ± SD 8.3 ± 1.6 vs. 4.3 ± 1.7, p < .001, respectively).

CONCLUSION

The AAPQ is a valid and reliable questionnaire that provides an assessment of caregivers' knowledge of their child's AAP and can guide educational interventions by healthcare providers.

Pediatric emergency department-based asthma education tools and parent/child asthma knowledge

Asthma exacerbations are a leading cause of pediatric hospitalizations despite multiple efforts to educate patients and families on disease course and medication management. Asthma education in the pediatric emergency department (ED) is challenging, and although the use of written action plans has been associated with reduction in hospitalizations and ED visits, written tools may not be useful for individuals with low health literacy. Moreover, asthmatic children should participate in their asthma education. In this prospective randomized study of 53 families presenting to a pediatric ED with a child experiencing an asthma exacerbation, education on asthma was presented via an interactive mobile-based video-game versus a standard-of-care asthma education video (SAV). Median age was 10 years; 64% were males. Many patients had moderate-to-severe asthma, with 57% experiencing ≥ 2 asthma-related ED visits in the last year, 58% requiring hospitalization and 32% reporting a critical care admission. In this cohort, the mobile-based video-game was found to be a feasible, acceptable educational tool; 86% of parents and 96% of children liked the game, while 96% of parents and 76% of children preferred playing the game over watching a SAV. Despite a history of persistent asthma, only 34% of children used an inhaled corticosteroid while 70% required rescue inhaler use in the prior week. Basic asthma knowledge was sub-optimal with only 60% of parents and 43% of children correctly recognizing symptoms that should prompt immediate medical care. This reflects a major gap in asthma knowledge that coexists with parental misconceptions regarding optimal asthma management.

Pediatric Resident Communication of Hospital Discharge Instructions

OBJECTIVE

Suboptimal provider-parent communication contributes to poor parent comprehension of pediatric discharge instructions, which can lead to adverse outcomes. Residency is a critical window to acquire and learn to utilize key communication skills, potentially supported by formal training programs or visual reminders. Few studies have examined resident counseling practices or predictors of counseling quality. Our objectives were to (1) examine pediatric resident counseling practices and (2) determine how formal training and presence of discharge templates with domain-specific prompts are associated with counseling.

METHODS

We conducted a cross-sectional survey of a convenience sample of residents in the American Academy of Pediatrics Section on Pediatric Trainees. Outcomes included resident self-report of frequency of (1) counseling in domains of care and (2) use of health literacy-informed counseling strategies (pictures, demonstration, Teach Back, Show Back) (6-point scales; frequent = often/usually/always). Predictor variables were (1) formal discharge-related training (e.g., lectures) and (2) hospital discharge instruction template with space for individual domains. Logistic regression analyses, utilizing generalized estimating equations when appropriate to account for multiple domains (adjusting for resident gender, postgraduate year), were performed.

KEY RESULTS

Few residents (N = 317) (13.9%) reported formal training. Over 25% of residents infrequently counsel on side effects, diagnosis, and restrictions. Resident reported use of communication strategies was infrequent: drawing pictures (24.1%), demonstration (15.8%), Teach Back (36.8%), Show Back (11.4%). Designated spaces in instruction templates for individual domains were associated with frequent domain-specific counseling (adjusted odds ratio [aOR] 4.1 [95% confidence interval: 3.5-4.8]). Formal training was associated with frequent Teach Back (aOR 2.6 [1.4-5.1]) and Show Back (aOR 2.7 [1.2-6.2]).

CONCLUSIONS

Lack of formal training and designated space for domain-specific instructions are associated with suboptimal counseling at discharge by pediatric residents. Future research should focus on determining the best mechanisms for teaching trainees communication skills and optimizing written instruction templates to support verbal counseling. [HLRP: Health Literacy Research and Practice. 2023;7(4):e178-e186.].

Health Information on Pre-Exposure Prophylaxis From Search Engines and Twitter: Readability Analysis

BACKGROUND

Pre-exposure prophylaxis (PrEP) is proven to prevent HIV infection. However, PrEP uptake to date has been limited and inequitable. Analyzing the readability of existing PrEP-related information is important to understand the potential impact of available PrEP information on PrEP uptake and identify opportunities to improve PrEP-related education and communication.

OBJECTIVE

We examined the readability of web-based PrEP information identified using search engines and on Twitter. We investigated the readability of web-based PrEP documents, stratified by how the PrEP document was obtained on the web, information source, document format and communication method, PrEP modality, and intended audience.

METHODS

Web-based PrEP information in English was systematically identified using search engines and the Twitter API. We manually verified and categorized results and described the method used to obtain information, information source, document format and communication method, PrEP modality, and intended audience. Documents were converted to plain text for the analysis and readability of the collected documents was assessed using 4 readability indices. We conducted pairwise comparisons of readability based on how the PrEP document was obtained on the web, information source, document format, communication method, PrEP modality, and intended audience, then adjusted for multiple comparisons.

RESULTS

A total of 463 documents were identified. Overall, the readability of web-based PrEP information was at a higher level (10.2-grade reading level) than what is recommended for health information provided to the general public (ninth-grade reading level, as suggested by the Department of Health and Human Services). Brochures (n=33, 7% of all identified resources) were the only type of PrEP materials that achieved the target of ninth-grade reading level.

CONCLUSIONS

Web-based PrEP information is often written at a complex level for potential and current PrEP users to understand. This may hinder PrEP uptake for some people who would benefit from it. The readability of PrEP-related information found on the web should be improved to align more closely with health communication guidelines for reading level to improve access to this important health information, facilitate informed decisions by those with a need for PrEP, and realize national prevention goals for PrEP uptake and reducing new HIV infections in the United States.

Addressing Health Literacy in Pediatric Practice: A Health Equity Lens

Low health literacy has been linked to worse child health-related knowledge, behaviors, and outcomes across multiple health domains. As low health literacy is highly prevalent and an important mediator of income- and race/ethnicity-associated disparities, provider adoption of health literacy best practices advances health equity. A multidisciplinary effort involving all providers engaged in communication with families should include a universal precautions approach, with clear communication strategies employed with all patients, and advocacy for health system change.

Development and assessment of a low literacy, pictographic asthma action plan with clinical automation to enhance guideline-concordant care for children with asthma

OBJECTIVE

Asthma is characterized by reversible pulmonary symptoms, frequent hospitalizations, poor quality of life, and varied treatment. Parents with low health literacy (HL) is linked to poor asthma outcomes in children. Recent practice updates recommended inhaled corticosteroids for the management of persistent asthma, but guideline-concordant care is suboptimal. Our aim was to develop and assess an Asthma Action Plan (AAP) that could serve as an individualized plan for low HL families and facilitate guideline-concordant care for clinicians.

METHODS

We followed the National Institute of Health 5-step "Clear & Simple" approach to develop the Uniformed Services AAP. Our AAP included symptom pictographs (dyspnea, cough, sleep, activity) and guideline-concordant clinical automation tools. Caregivers assessed the pictograms for validity (transparency of ≥ 85%; translucency score ≥ 5; and ≥ 85% recall). Readability was assessed using 7 formulas. (<6th Grade was acceptable). Comprehensibility, design quality, and usefulness was assessed by caregivers using the Consumer Information Rating Form (CIRF) (>80% was acceptable). Understandability and actionability was assessed by medical librarians using the Patient Education Materials Assessment Tool-Printable (>80% was acceptable). Suitability was assessed by clinicians using the modified Suitability Assessment of Materials (SAM) instrument (>70% was superior).

RESULTS

All 12 pictograms were validated (N = 118 respondents). Readability demonstrated a 4th grade level. Overall CIRF percentile score = 80.4%. Understandability and Actionability = 100%. Suitability score = 75%.

CONCLUSIONS

Our AAP was formally endorsed by the Allergy & Asthma Network. The Uniformed Services AAP is a novel tool with embedded clinical automation that can address low HL and enhance guideline-concordant care.

Patient education information material assessment criteria: A scoping review

BACKGROUND

Patient education information material (PEIM) is an essential component of patient education programs in increasing patients' ability to cope with their diseases. Therefore, it is essential to consider the criteria that will be used to prepare and evaluate these resources.

OBJECTIVE

This paper aims to identify these criteria and recognize the tools or methods used to evaluate them.

METHODS

National and international databases and indexing banks, including PubMed, Scopus, Web of Science, ProQuest, the Cochrane Library, Magiran, SID and ISC, were searched for this review. Original or review articles, theses, short surveys, and conference papers published between January 1990 and June 2022 were included.

RESULTS

Overall, 4688 documents were retrieved, of which 298 documents met the inclusion criteria. The criteria were grouped into 24 overarching criteria. The most frequently used criteria were readability, quality, suitability, comprehensibility and understandability.

CONCLUSION

This review has provided empirical evidence to identify criteria, tools, techniques or methods for developing or evaluating a PEIM. The authors suggest that developing a comprehensive tool based on these findings is critical for evaluating the overall efficiency of PEIM using effective criteria.

Providing a Constipation Action Plan to Families of Children With Constipation Decreases Health Care Utilization

OBJECTIVES

To evaluate whether providing a constipation action plan (CAP) to families of children with constipation at outpatient gastroenterology (GI) visits affects health care utilization of the GI department.

METHODS

We created a CAP to be included in the after visit summary of children seen in our GI Clinic. We compared the number of patient telephone calls, electronic messages, and urgent care (UC) visits, emergency department (ED) visits, and hospitalizations within 3 months after the visit of patients who received the CAP compared to those who did not using inverse probability treatment weighting (IPTW) analysis. For families who received the CAP at a follow-up visit, we compared these variables in the 3 months before and after the CAP was provided using paired t test and McNemar's test as appropriate.

RESULTS

We included 336 patients who received the CAP and 2812 who did not. After IPTW adjustment, there were fewer patient telephone calls for patients who received the CAP (P = 0.0006). The difference in patient electronic messages was not statistically significant (P = 0.09). For the 45 patients who received the CAP at a follow-up visit, there were on average 1.8 more patient telephone calls made prior to receiving the CAP than after (95% confidence interval (CI) = 0.8-2.8; P = 0.0007) and 2.3 more patient electronic messages received (95% CI = 0.1-4.5; P = 0.04). There were no differences in UC/emergency department visits or hospitalizations.

CONCLUSIONS

We found that providing a CAP to families of children with constipation decreases health care utilization. Further studies are needed to determine whether this impacts patient outcomes.

Development and Assessment of a Low Literacy, Pictographic Cyclic Vomiting Syndrome Action Plan

OBJECTIVE

To develop and assess an evidence-based, individualized Cyclic Vomiting Syndrome Action Plan (CVSAP) to optimize both preventative and acute care.

STUDY DESIGN

This implementation science project synthesized a combination of clinical practice guidelines, published literature, and clinical experience by a team of CVS clinicians to develop the CVSAP. The tool was developed to include validated pictograms and an automatic, embedded, weight-based dosing calculator to output acute management recommendations. The final version of the CVSAP was tested by patients/caregivers, readability calculators, medical librarians, and clinicians using validated metrics.

RESULTS

All pictograms met the criteria for inclusion in the CVSAP. A composite readability score of 5.32 was consistent with a fifth-grade level. Patients/caregivers (n = 70) judged the CVSAP to be of high quality with consumer information rating form rating of 84.2%. Six medical librarians rated the CVSAP to have 93% understandability and 100% actionability, and 33 clinicians completing the SAM generated a suitability rating of 87.5%.

CONCLUSIONS

The CVSAP visually highlights individualized care plan components to facilitate optimized preventative and acute CVS care. Further investigation will determine if CVSAP increases caregiver confidence and compliance in home management and improves quality of life and clinical outcomes for patients with CVS.

Development and assessment of a low-health-literacy, pictographic adrenal insufficiency action plan

OBJECTIVES

Adrenal insufficiency (AI) is an overall rare disorder characterized by the chronic need for pharmacotherapy to prevent threat to life. The Pediatric Endocrine Society has recommended the use of clinical action tools to improve patient education and help guide acute management of AI. We aimed to develop and assess an easy-to-use, patient-friendly, evidence-based, personalized pictogram-based adrenal insufficiency action plan (AIAP) to aid in the management of AI in children.

METHODS

Patients/caregivers (P/Cs) responded to surveys which measured the concepts of transparency, translucency, and recall in order to assess the pictograms. Readability was assessed using six formulas to generate a composite readability score. Quality was graded by P/Cs using the Consumer Information Rating Form (CIRF) (>80% rating considered acceptable). Understandability and actionability was assessed by medical librarians using the Patient Education Materials Assessment Tool-Printable (PEMAT-P) (>80% rating was acceptable). Suitability was evaluated by clinicians using the Suitability Assessment of Materials (SAM) instrument (>70% rating considered superior).

RESULTS

All pictograms met criteria for inclusion in the AIAP. Composite readability score=5.4 was consistent with a fifth-grade level. P/Cs (n=120) judged the AIAP to be of high quality with CIRF rating=85.2%. Three medical librarians rated the AIAP to have 100% understandability and 100% actionability. Thirty-three clinicians completing the SAM generated a suitability rating of 90.0%.

CONCLUSIONS

The AIAP visually highlights individualized care plan components to facilitate optimized preventative and acute AI care. Further investigation will determine if AIAP improves clinical outcomes for patients with AI.

The Impact of Adherence and Health Literacy on Difficult-to-Control Asthma

Medication nonadherence and health literacy are key factors that influence the management of difficult-to-control asthma. Adherence, or the extent to which a patient follows a treatment plan, extends beyond asthma medication use and includes an appropriate inhaler technique. Assessment of adherence is critical before making a diagnosis of severe asthma and stepping up asthma therapy but is challenging in the clinical context. Health literacy, or the degree to which individuals can obtain, process, and understand health information and services needed to make health care decisions, is additionally important for asthma management and has been shown to impact medication adherence. Initiatives aiming to improve difficult-to-control asthma should address medication adherence and health literacy. Universal health literacy precautions are recommended while communicating with patients, in addition to the creation of low health literacy asthma action plans. To improve adherence, a comprehensive assessment of adherence should be conducted. Additional evidence-based interventions aiming to improve adherence focus on appropriate inhaler use, improved access to medications, the use of digital platforms, school-based asthma interventions, and the implementation of culturally tailored interventions. Data are limited regarding the use of these initiatives in patients with severe or difficult-to-control asthma.

Chronic pediatric diseases and risk for reading difficulties: a narrative review with recommendations

Literacy is a major social determinant of health, rooted in skills that develop during early childhood. Children arriving at kindergarten unprepared to learn to read are more likely to have low reading proficiency thereafter. General and health literacy are highly correlated, affecting understanding of health conditions, treatment adherence, and transition to self-care and adult healthcare services. The American Academy of Pediatrics (AAP) recommends literacy and school readiness promotion during well-visits and neurodevelopmental surveillance is emphasized across primary and subspecialty care. While genetic and environmental risk factors for reading difficulties are well-established, risks related to complex and chronic medical conditions are less appreciated and under-researched. This review applies an eco-bio-developmental framework to explore literacy across five complex chronic conditions affecting millions of children worldwide: asthma, cancer, congenital heart disease, epilepsy, and sickle cell disease. In each, integration of an efficient reading brain network may be impacted by direct factors, such as ischemia, anesthesia, and/or medications, and also indirect factors, such as altered parent-child routines, hospital stays, and missed school. By integrating literacy into care management plans for affected children, pediatric primary care and specialty providers are poised to identify risks early, target guidance and interventions, and improve academic and health outcomes. IMPACT: While genetic and environmental risk factors for reading difficulties are well-established, risks related to complex and/or chronic medical conditions such as asthma, cancer, congenital heart disease, epilepsy, and sickle cell disease are substantial, less appreciated, and under-researched. General and health literacy are highly correlated, with implications for the understanding one's health condition, treatment adherence, and transitioning to self-care, which is especially important for children with complex and/or chronic illness. Pediatric primary care and specialty providers are poised to integrate reading and literacy into care management plans for children with complex and/or chronic illness, including early screening, guidance, support, and interventions.

Developing an Asthma Self-management Intervention Through a Web-Based Design Workshop for People With Limited Health Literacy: User-Centered Design Approach

Background

Technology, including mobile apps, has the potential to support self-management of long-term conditions and can be tailored to enhance adoption. We developed an app to support asthma self-management among people with limited health literacy in a web-based workshop (to ensure physical distancing during the COVID-19 pandemic).

Objective

The aim of this study is to develop and test a prototype asthma self-management mobile app tailored to the needs of people with limited health literacy through a web-based workshop.

Methods

We recruited participants from a primary care center in Malaysia. We adapted a design sprint methodology to a web-based workshop in five stages over 1 week. Patients with asthma and limited health literacy provided insights into real-life self-management issues in stage 1, which informed mobile app development in stages 2-4. We recruited additional patients to test the prototype in stage 5 using a qualitative research design. Participants gave feedback through a concurrent thinking-aloud process moderated by a researcher. Each interview lasted approximately 1 hour. Screen recordings of app browsing activities were performed. Interviews were audio-recorded and analyzed using a thematic approach to identify utility and usability issues.

Results

The stakeholder discussion identified four themes: individual, family, friends, and society and system levels. Five patients tested the prototype. Participants described 4 ways in which the app influenced or supported self-management (utility): offering information, providing access to an asthma action plan, motivating control of asthma through support for medication adherence, and supporting behavior change through a reward system. Specific usability issues addressed navigation, comprehension, and layout.

Conclusions

This study proved that it was possible to adapt the design sprint workshop to a web-based format with the added advantage that it allowed the development and the testing process to be done efficiently through various programs. The resultant app incorporated advice from stakeholders, including sources for information about asthma, medication and appointment reminders, accessible asthma action plans, and sources for social support. The app is now ready to move to feasibility testing.

Quality and readability of French on-line information about otitis media with effusion

INTRODUCTION

Childhood otitis media with effusion (OME) is a frequent disease often misunderstood by parents. Information on the Internet is of variable quality and readability. The aim of this study was to measure the quality and readability of French websites related to OME.

MATERIAL AND METHODS

An advanced Google search was conducted using the terms "Otite séro-muqueuse OR Otite séreuse". Quality was assessed on DISCERN criteria. Readability was assessed using Flesch Reading Ease Scoring (FRES), Flesch-Kincaid Grade Level (FKGL), the Simple Measure of Gobbledygook (SMOG) and a Fry graph. Medians and standard deviations were calculated. Correlation between quality and readability was assessed on Spearman r coefficient.

RESULTS

The first ten websites meeting inclusion and exclusion criteria were evaluated. One had been updated during the last 12 months. Median DISCERN score was 49±13.7/80. Median FRES score was 46±9.5/100. Median USA grade-level estimated by FKGL and SMOG respectively was 11±1.7 and 12±1.5. Six websites had Fry score>12. One website showed high quality. One had a readability score in the target range (below 9th grade reading level (age 14-15)) according to FRES and FKGL. A suggestive correlation was found between lower SMOG readability and higher quality: r=0.72 (P=0.024). Three websites followed the most recent scientific guidelines.

CONCLUSION

Online information about OME was of variable quality and readability. Good quality information tended to be less easily understandable by parents.

Empowering children and young people who have asthma

Asthma is the most common chronic condition of childhood. In this review, we discuss an overview of strategies to empower children and young people with asthma. The key aspects of empowerment are to enable shared decision making and self-management, and help children minimise the impact of asthma on their life. The evidence behind these strategies is either sparse or heterogenous, and it is difficult to identify which interventions are most likely to improve clinical outcomes. Wider determinants of health, in high-resource and low-resource settings, can be disempowering for children with asthma. New approaches to technology could help empower young people with asthma and other chronic health conditions.

Development and Assessment of a Pictographic Pediatric Constipation Action Plan

OBJECTIVE

To assess the Uniformed Services Constipation Action Plan (USCAP) as an evidence-based, personalized, clinical action tool with pictograms to aid clinicians and families in the management of functional constipation.

STUDY DESIGN

The USCAP facilitates the management functional constipation by using a health literacy-informed approach to provide instructions for pharmacotherapies and lifestyle modifications. This study included part 1 (pictogram validation) and part 2 (assessment). For part 1, pictogram transparency, translucency, and recall were assessed by parent survey (transparency ≥85%, mean translucency score ≥5, recall ≥85% required for validation). For part 2, the USCAP was assessed by parents, clinical librarians, and clinicians. Parental perceptions (n = 65) were assessed using the Consumer Information Rating Form (17 questions) to gauge comprehensibility, design quality and usefulness. Readability was assessed by 5 formulas and a Readability Composite Score was calculated. Clinical librarians (n = 3) used the Patient Education Materials Assessment Tool to measure understandability (19 questions) and actionability (7 questions) (>80% rating was acceptable). Suitability was assessed by clinicians (n = 34) using Doak's Suitability Assessment of Materials (superior ≥70% rating).

RESULTS

All 12 pictograms demonstrated appropriate transparency, translucency, and recall. Parental perceptions reflected appropriate comprehensibility, design quality, and usefulness. The Readability Composite Score was consistent with a fifth-grade level. Clinical librarians reported acceptable understandability and actionability. Clinicians reported superior suitability.

CONCLUSIONS

The USCAP met all criteria for clinical implementation and future study of USCAP implementation for treating children with chronic functional constipation.

Parental perception of a picture-based chronic asthma care management tool in an urban pediatric emergency department

BACKGROUND

National asthma guidelines recommend use of an asthma action plan (AAP) as part of chronic asthma care. Unfortunately, AAPs have not been tailored for use in acute care settings, where many patients at risk for poor chronic asthma care are seen, including those who are non-English-speaking or have low literacy levels. We previously developed a picture-based medication plan (PBMP), a unique type of AAP for use in an ambulatory setting and designed to increase patient use and understanding. However, little is known about how parents seeking emergency department (ED) asthma care would perceive the PBMP.

OBJECTIVE

To assess parental attitudes toward an asthma PBMP in the largest pediatric ED in Los Angeles County.

METHODS

We surveyed a consecutive sample of English- or Spanish-speaking parents of children 2-17 years seeking ED asthma care. Parents used a 5-point Likert scale for various statements regarding their perceptions of the PBMP. Responses were analyzed by sociodemographics, asthma control, and health literacy using Chi-squared and t-tests.

RESULTS

90 parents provided feedback on the PBMP. The majority of parents endorsed the PBMP. Endorsement was 20%-30% higher among Spanish-speaking parents and those who did not complete high-school compared to English-speaking parents and parents with a high school education or higher (p < 0.05 for both comparisons).

CONCLUSION

Spanish-speaking parents and parents with less than a high-school education overwhelmingly endorsed the PBMP. It may be useful to consider incorporating the PBMP as part of patient-centered chronic asthma care strategies for populations seen in ED settings.

Reading Level of Online Patient Education Materials From Major Obstetrics and Gynecology Societies

OBJECTIVE

To assess whether the readability of online patient education materials provided by eight nationally recognized obstetrics and gynecology societies is in accordance with the recommended 6th-grade reading level outlined by the American Medical Association, National Institute of Health, and United States Department of Health and Human Services.

METHODS

An analysis of 410 online patient education materials from the American Association of Gynecologic Laparoscopists, the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, the American Urogynecologic Society, the Association of Reproductive Health Professionals, the Society of Gynecologic Oncology, the Society for Maternal-Fetal Medicine, and Voices for Pelvic Floor Disorders was completed, and the readability scores using the Flesch-Kincaid Grade Level, Flesch Reading Ease, Gunning Fog Scale, and Simple Measure of Gobbledygook readability scales were calculated. These scales are used to assess print and web-based written material across a wide range of medical specialties and are endorsed by the National Institutes of Health. All four scales are computer-based assessments of readability that consider word count, number of syllables, and length of sentences when calculating a score that corresponds to grade level.

RESULTS

Majority of the patient education materials across all eight obstetrics and gynecology societies had readability scores above the recommended 6th-grade reading level. The average reading level for the 69 obstetrics-related articles ranged from 9th to 12th grade. The mean grade level for the 341 gynecology articles had a similar range across the four readability scales.

CONCLUSION

Online patient education materials provided by major obstetrics and gynecology societies do not currently adhere to recommended readability guidelines. Continued efforts to provide accessible and informative patient education materials is recommended to help improve health literacy for women.

Asthma and the Public School Teacher: A Two State Study

Background: Asthma is one of the most common chronic health problems experienced by school-age children. As a result, school professionals need to be well informed about this chronic illness so that they can adequately support the needs of students with asthma. Methods: This study examines data collected from a sample of teachers (n = 593) in 2 large southeastern states regarding their familiarity with asthma self-carry and self-administration laws and policies and training received related to general chronic health conditions including asthma. Results: Teachers, on average, reported little training received at either undergraduate or graduate levels. Although teachers noted knowledge about asthma, acquired through in-service training or to a lesser degree formal education, a high percentage of teachers reported receiving no asthma-related training through such approaches. Conclusions: Data in this study are consistent with data collected in a similar study in 2001 suggesting that while asthma prevalence has increased, education about the condition has not. Implications for school teachers, school administrators, school nurses, teacher educators, and asthma education personnel are provided.

Health Literacy in the Inpatient Setting: Implications for Patient Care and Patient Safety

Health literacy plays a role in the events leading up to children's hospitalizations, during hospital admission, and after discharge. Hospitals and providers should use a universal precautions approach and routinely incorporate health-literacy-informed strategies in communicating with all patients and families to ensure that they can understand health information, follow medical instructions, participate actively in their own/their child's care, and successfully navigate the health care system. Interventions that incorporate health-literacy-informed strategies and that target patients/families and health care systems should be implemented to improve patient outcomes and patient-centered and family-centered care.

Evidence-Based Review of Smartphone Versus Paper Asthma Action Plans on Asthma Control

Objective: To summarize and evaluate existing literature regarding the impact of mobile asthma action plans (MAAPs) versus written asthma action plans (WAAPs) on degree of asthma control. Data Sources: PubMed, EMBASE, Web of Science, and ClinicalTrials.gov were searched (2000-January 2019) using the term asthma action plan with each of the following: smartphone, computers, handheld, mobile applications, portable electronic application, portable software application, tablet, or technology. Study Selection and Data Extraction: The search was limited to cohort and randomized controlled trials examining MAAP versus WAAP data. Data extracted included the following: study design, population, intervention, control, outcomes related to asthma control, and potential biases assessed using Cochrane Collaboration's Risk of Bias Assessment Tool. Data Synthesis: Four of the 41 studies identified were included, each of which were randomized control trials. One study showed significant improvement using a non-asthma-specific assessment tool, 1 study showed improvement only for patients with uncontrolled asthma at baseline, and 2 studies showed no difference in asthma control scores. Overall risk of bias across all studies was low to moderate. Relevance to Patient Care and Clinical Practice: Health care providers should select an asthma action plan (AAP) format based on what the patient is most likely to understand and consistently use. Conclusions: Because of conflicting published data regarding the use of MAAPs versus WAAPs and risk of bias, it is unclear at this time whether one format of AAP is superior to the other for either adolescents or adults.

Health Literacy: Implications for Child Health

Health literacy is an important issue to consider in the provision of health-care to children. Similar to the adult population, most parents face health literacy challenges. Of particular concern, 1 in 4 parents have low health literacy, greatly affecting their ability to use health information to make health decisions for their child. High expectations are placed on parents and children to achieve effective disease management and positive health outcomes in the context of complex health-care systems and disease treatment regimens. Low health literacy affects parent acquisition of knowledge, attitudes, and behaviors, as well as child health outcomes across the domains of disease prevention, acute illness care, and chronic illness care. The effect of low health literacy is wide ranging, including 1) poor nutrition knowledge and behaviors, 2) higher obesity rates, 3) more medication errors, 4) more emergency department use, and 5) poor asthma knowledge, behaviors, and outcomes. Health-care providers can mitigate the effects of health literacy by seeking to align health-care demands with the health literacy skills of families. Effective health literacy-informed interventions provide insights into methods that can be used by providers and health systems to improve health outcomes. Health literacy-informed communication strategies should be used with all families in a "universal precautions approach" because all parents likely benefit from clear communication. As scientific advances are made in disease prevention and management, unless families understand how to follow provider recommendations, the benefit of these advances will not be realized and disparities in outcomes will be exacerbated.

Review of the quality of printed patient education materials on asthma available in primary care in Singapore

Objective: Patient education materials (PEMs) are commonly used for patient education. This study assessed readability, format quality, accuracy, understandability and actionability of printed asthma PEMs available in primary care in Singapore.Methods: Primary care in Singapore is provided by island-wide polyclinics and private general practices. We invited the three polyclinic healthcare groups and private general practices via the Primary Care Research Network to submit asthma-related PEMs. Readability was assessed using Simple Measure of Gobbledegook (SMOG) and Flesch-Kincaid (FK) score. Format quality was assessed using "Clear-print and large-print golden rules" from UK Association for Accessible Formats (UKAAF). Understandability and actionability were evaluated using Patient Education Materials Assessment Tool - Printed. Three pulmonologists assessed content accuracy.Results: Thirty leaflets were assessed. SMOG and FK estimated 93% (mean 9.3, range 5-14, SD 1.8) and 47% (mean 6.8, range 2.4-9.9, SD 2.0) exceeded the recommended sixth-grade reading level, respectively. About a third (37%) were fully concordant with UKAAF guidelines, with poor format quality contributed by small font size, poor text emphasis methods, and not using left-aligned text. Leaflets generally scored well in both understandability (mean 84%) and actionability (mean 72%). Thirteen leaflets were inaccurate, 92% of which contained at least one inaccuracy judged to have potentially harmful consequences to patients, including wrong emergency advice.Conclusion: While understandability and actionability are adequate, current asthma PEMs are limited by inappropriately high reading levels, poor format quality and inaccuracies. Healthcare professionals need to assess patients' reading abilities and ensure PEMs are accurate and suitable for their patients.

Challenges When Translating and Culturally Adapting a Measurement Instrument: The Suitability and Comprehensibility of Materials (SAM+CAM)

There is evidence that low suitability and comprehensibility of printed education materials (PEMs) affects patients’ and relatives’ ability to read and comprehend information. However, few instruments measure the suitability of written information, and none exist in the Swedish language. The aim was to describe the translation and adaptation of the Suitability and Comprehensibility of Materials (SAM+CAM) instrument into the Swedish language and health care context and to explore challenges related to this process. The SAM+CAM instrument was translated and culturally adapted in five steps: forward translation, synthesis, back translation, expert review, and pretests. Differences were found when translating and culturally adapting the SAM+CAM instrument in the areas of semantic, idiomatic, and experiences. Participants revealed several clarity inconsistencies between items. They also identified linguistic differences and unfamiliar wording; they found that the instrument was perplexing to use and lacked knowledge regarding the specific health care areas in the examined PEMs. The cultural perspective is a significant factor that influences the usability of PEMs. Therefore, expert groups of participants are useful when adapting instruments to different cultures. The Swedish SAM+CAM instrument requires experienced and highly qualified raters.

The readability, suitability, and content features of eczema action plans in the United States

BACKGROUND/OBJECTIVES

Little is known about the reading grade level (readability), appropriateness of design (suitability), and content variability of written eczema action plans (EAPs), which can impact the effectiveness of these patient education tools. Here, we assess the readability, suitability, and content of EAPs currently used by pediatric dermatologists in the United States.

METHODS

This was a cross-sectional study of EAPs submitted by members of the Society for Pediatric Dermatology (n = 26). Readability, suitability, and content of sampled plans were systematically assessed.

RESULTS

Mean (SD) reading grade level was 9.0 (2.1); one in five was written at the recommended level of 6th grade or lower. While the majority of EAPs were found to be adequately suitable, one in five was unsuitable and only two superior. Documents scored most poorly in layout/design and learning stimulation. Plans scored best in the categories of content and literacy demand. EAPs focused on similar content themes, though specific recommendations and descriptors of atopic dermatitis (AD) disease states varied considerably.

CONCLUSIONS

The health literacy burden of EAPs in the United States could be lowered by improving their readability, incorporating graphics, stimulating reader engagement, and developing standards for how AD flares are defined.

Home Management of Childhood Asthma Exacerbations

Introduction

Effective home management of childhood asthma by caregivers requires education along with a written asthma action plan (AAP), which should outline clear instructions for treatment during exacerbations. However, a large number of asthma exacerbations continue to be managed in the emergency department (ED) and in hospitals, particularly in Canada. The objective of this study was to assess caregiver management of acute asthma at home following the 2015 Global Initiative for Asthma (GINA) guidelines and to identify factors that may be associated with deviations from these guidelines.

Methods

122 caregivers of children, aged 3–17 years, with physician diagnosed asthma, completed a paper-based questionnaire. Correct caregiver management (defined according to the GINA guidelines) of acute asthma as well as their use of an AAP were assessed.

Results

Out of all caregivers, 74.6% incorrectly treated their child’s asthma exacerbation in a home setting. Among those who used an AAP, we observed significantly more ED visits (0.9 ± 1.2 versus 0.5 ± 0.9, p = 0.04) and hospitalizations (0.2 ± 0.4 versus 0.0 ± 0.0, p = 0.02) when compared to non-AAP users in the past 1 year.

Conclusions

Caregivers of children with asthma in Canada may still lack skills for proper home management of asthma exacerbations. We found a higher number of ED visits and hospitalizations in those using an AAP compared to those who did not use an AAP. These data suggest that current AAPs may not be sufficient for home asthma management.

Electronic supplementary material

The online version of this article (10.1007/s41030-018-0061-y) contains supplementary material, which is available to authorized users.

What is the quality of drug safety information for patients: An analysis of REMS educational materials

Background

Poor‐quality patient drug information has been identified as a major cause of preventable medication errors in the United States. The US Food and Drug Administration (FDA) has the authority to require marketing authorization holders of medicinal products to implement risk evaluation and mitigation strategies (REMS) to ensure that the benefits of a drug or biological product outweigh its risks. Aside from medication guides, no research has been conducted to assess the quality of patient‐targeted REMS materials, including whether, and to what extent, patients find these materials understandable and actionable.

Purpose

To describe the readability, understandability, and actionability of patient educational materials in currently approved REMS programs, and to highlight opportunities for improving both the quality and effectiveness of these important drug safety tools.

Methods

Seventy‐seven REMS programs were identified from the FDA REMS database. We excluded medication guides (MGs) from our analysis because of the fact that there is a mandatory MG template. Based on this, we identified a total of 27 (non‐MG) REMS patient materials on the FDA REMS website for analysis purposes. The materials were tested for readability using the Lexile Measure, the Gunning Fog Index, and Flesch Kincaid and then assessed using the Patient Education Materials Assessment Tool for printable materials, for understandability and actionability.

Results

Twenty‐three of 77 (30%) REMS programs used educational materials to communicate serious risks to patients, yielding a total of 27 REMS patient materials for analysis. The median readability score for these materials was at a ninth‐grade reading level or higher. While most (89%) of these patient education materials met established criteria for being understandable, less than half (49%) were deemed actionable.

Discussion

Currently approved REMS patient materials fell short in terms of recommended reading level, and over half did not meet recommended standards for actionability. Developers of these materials should apply plain language principles when design these materials to improve their readability and to assess both understandability and actionability in order to increase the effectiveness when distributed to patients.

What parents are reading about laryngomalacia: Quality and readability of internet resources on laryngomalacia

OBJECTIVE

The goal of this study is to measure the quality and readability of websites related to laryngomalacia, and to compare the quality and readability scores for the sites accessed through the most popular search engines.

INTRODUCTION

Laryngomalacia is a common diagnosis in children but is often difficult for parents to comprehend. As information available on the internet is unregulated, the quality and readability of this information may vary.

METHODS

An advanced search on Google, Yahoo, and Bing was conducted using the terms "laryngomalacia" OR "soft larynx" OR "floppy voice box." The first ten websites meeting inclusion and exclusion criteria were evaluated, for each search engine. Quality and readability were assessed using the DISCERN criteria and the Flesch reading ease scoring (FRES) and Flesch-Kincaid grade level (FKGL) tests, respectively.

RESULTS

The top 10 hits on each search engine yielded 15 unique web pages. The median DISCERN score (out of a possible high-score of 80) was 48.5 (SD 12.6). The median USA grade-level estimated by the FKGL was 11.3 (SD 1.4). Only one website (6.7%), had a readability score in the optimal range of 6th to 8th grade reading level. DISCERN scores did not correlate with FKGL scores (r = 0.10).

CONCLUSION

Online information discussing laryngomalacia often varies in quality and may not be easily comprehensible to the public. It is important for healthcare professionals to understand the quality of health information accessible to patients as it may influence medical decision-making by patient families.

Harnessing Reddit to Understand the Written-Communication Challenges Experienced by Individuals With Mental Health Disorders: Analysis of Texts From Mental Health Communities

BACKGROUND

Mental disorders such as depression, bipolar disorder, and schizophrenia are common, incapacitating, and have the potential to be fatal. Despite the prevalence and gravity of mental disorders, our knowledge concerning everyday challenges associated with them is relatively limited. One of the most studied deficits related to everyday challenges is language impairment, yet we do not know how mental disorders can impact common forms of written communication, for example, social media.

OBJECTIVE

The aims of this study were to investigate written communication challenges manifest in online mental health communities focusing on depression, bipolar disorder, and schizophrenia, as well as the impact of participating in these online mental health communities on written communication. As the control, we selected three online health communities focusing on positive emotion, exercising, and weight management.

METHODS

We examined lexical diversity and readability, both important features for measuring the quality of writing. We used four well-established readability metrics that consider word frequencies and syntactic complexity to measure writers' written communication ability. We then measured the lexical diversity by calculating the percentage of unique words in posts. To compare lexical diversity and readability among communities, we first applied pairwise independent sample t tests, followed by P value adjustments using the prespecified Hommel procedure to adjust for multiple comparison. To measure the changes, we applied linear least squares regression to the readability and lexical diversity scores against the interaction sequence for each member, followed by pairwise independent sample t tests and P value adjustments. Given the large sample of members, we also report effect sizes and 95% CIs for the pairwise comparisons.

RESULTS

On average, members of depression, bipolar disorder, and schizophrenia communities showed indications of difficulty expressing their ideas compared with three other online health communities. Our results also suggest that participating in these platforms has the potential to improve members' written communication. For example, members of all three mental health communities showed statistically significant improvement in both lexical diversity and readability compared with members of the OHC focusing on positive emotion.

CONCLUSIONS

We provide new insights into the written communication challenges faced by individuals suffering from depression, bipolar disorder, and schizophrenia. A comparison with three other online health communities suggests that written communication in mental health communities is significantly more difficult to read, while also consisting of a significantly less diverse lexicon. We contribute practical suggestions for utilizing our findings in Web-based communication settings to enhance members' communicative experience. We consider these findings to be an important step toward understanding and addressing everyday written communication challenges among individuals suffering from mental disorders.

Evaluation of Pediatric Human Papillomavirus Vaccination Provider Counseling Written Materials: A Health Literacy Perspective

BACKGROUND AND OBJECTIVES

Despite recommendations supporting human papillomavirus (HPV) vaccination, pediatric vaccination rates remain suboptimal in the United States; lack of tools to support provider counseling is one barrier. We sought to evaluate HPV-related counseling materials for readability, suitability, and content, and assess parent perceptions of materials, using a health literacy perspective.

METHODS

A systematic search was conducted for written materials developed for HPV vaccination counseling by examining state Department of Health Web sites and associated links to local and national organizations. Materials were assessed for the following: 1) readability (Flesch Reading Ease, Flesch-Kincaid, Gunning Fog, Simple Measure of Gobbledygook, Fry), 2) suitability (understandability and actionability) (Suitability Assessment of Materials; Patient Education Materials Assessment Tool for Printable Materials), and 3) coverage of 8 key content areas (recommended by Centers for Disease Control and Prevention). Semistructured interviews were conducted with English-speaking parents or caregivers of children 9 to 17 years of age from 3 pediatric clinics (New York, Ohio, Illinois) serving predominantly low-income families to assess perceptions and usefulness of 4 handouts selected for review.

RESULTS

Thirty-eight documents were assessed. Mean ± standard deviation (SD) reading grade level was 9.4 ± 2; 10.5% (n = 4) had a reading level of 6th grade or below; 68.4% (n = 26) were considered not suitable. Mean understandability was 41.7% and mean actionability was 20.7%. Only 5.3% (n = 2) addressed all 8 content areas mean ± SD (number of areas = 6.7 ± 1.2). Brochure comprehensiveness and inclusion of a personal story were cited as factors that would be helpful in influencing parents to vaccinate against HPV.

CONCLUSIONS

Few written materials for HPV vaccination counseling were optimal from a health literacy best practices perspective. Content comprehensiveness was important for informed decision making.

How are health literacy principles incorporated into breast cancer chemotherapy education? A review of the literature

BACKGROUND

Chemotherapy is commonly used in combination with other treatments for breast cancer. However, low adherence to chemotherapy is a growing concern, particularly among breast cancer patients. Side effects such as nausea and vomiting, fatigue, and arthralgia can contribute to reduced adherence. Other factors such as provider communication and limited insurance coverage can affect adherence. Studies have shown that as much as 28% of patients with breast cancer did not continue with their prescribed dose of chemotherapy. Research suggests that chemotherapy education materials can be critical to addressing problems with non-adherence, and may include written materials, verbal instruction, and multimedia programs. Despite this wide variety, the effectiveness and benefit of chemotherapy education hinges on the patients' health literacy. Breast cancer patients with low health literacy may be unclear about chemotherapy or face difficulty adhering to treatment if they do not understand the information provided to them. Thus, this scoping review summarizes the existing research on how health literacy principles are incorporated into breast cancer chemotherapy education materials.

METHODS

Using a combination of keywords (e.g. chemotherapy, education) and Medical subject headings (MeSH) terms (e.g., drug therapy, antineoplastic agents), we searched five databases (1977-2017): CINAHL, PubMed, PsycINFO, Cochrane Library, and Web of Science.

RESULTS

Eight of 4,624 articles met the inclusion criteria. Five articles incorporated health literacy principles (e.g., plain language, maintaining an active voice, using white space) into the development of written materials. Few articles used a theoretical framework to guide education material development (n = 3). Of the three articles that described pilot-testing of educational materials, two used post-tests only and one used a pre/post-test design.

CONCLUSIONS

Findings indicated that limited research exists regarding the use of health literacy principles in chemotherapy education materials. Much of the development of chemotherapy education is not grounded in theory and the application of health literacy principles is limited. Implementing health literacy principles may improve overall comprehension of education thereby increasing adherence.

Suitability of asthma education materials for school-age children: Implications for health literacy

AIMS AND OBJECTIVES

To investigate the suitability of asthma education materials for school-age children with asthma and elucidate how these children used their health-literacy abilities to identify whether the materials can be accepted, comprehended and applied.

BACKGROUND

Effective asthma self-management education is influenced by the suitability of materials and an individual's health literacy.

DESIGN

A mixed-method research design was developed using quantitative and qualitative surveys.

METHODS

The suitability of the materials was assessed on the basis of the Chinese version of the Suitability Assessment of Materials by five experts. In addition, five school-age children (age: 8-12 years) were recruited and interviewed.

RESULTS

In total, 25 pieces of asthma education material for children were collected. On the basis of their type, the materials were categorised as nine brochures, 11 leaflets and five videos. Of the 25 materials, 17 were rated as superior materials, whereas eight were rated as adequate materials. The suitability scores of the video-based materials were significantly higher than those of the brochures and leaflets (p = .006). One print material was considered to have a reading level suitable for fifth-grade or younger children, whereas the remaining materials were considered suitable for sixth-grade or older children. The following six health-literacy domains were identified: recognising asthma through body knowledge, posing reflective questions, identifying self-care difficulties, receiving adult guidance, learning with enjoyment and addressing learning requirements.

CONCLUSIONS

The video-based materials had integrated content and were appealing to children. Cartoon animations, interactive computer games, and skill demonstrations may enhance learning stimulation and motivation and increase learning effects in children.

RELEVANCE TO CLINICAL PRACTICE

The present results may help healthcare providers to understand children's capacities to manage their disease, effectively address children's requirements and function as a key resource for children to strengthen their literacy in asthma management.

Developing a written action plan for children with eczema: a qualitative study

Background

Eczema is common in children but adherence to treatments is poor. Written action plans (WAPs) have been shown to help in asthma but the potential value, format, and content of an eczema WAP is unknown.

Aim

To explore the potential role of an eczema WAP, and to design an eczema-specific WAP.

Design and setting

A qualitative study of parents of children with eczema, primary and secondary care health professionals, and other stakeholders.

Method

A total of 41 semi-structured one-to-one interviews and two focus groups were audiorecorded, transcribed, and analysed thematically.

Results

Reported challenges of managing eczema included: parental confusion about treatment application; lack of verbal and written advice from GPs; differing beliefs about the cause and management of eczema; re-prescribing of failed treatments; and parents feeling unsupported by their GP. An eczema WAP was viewed as an educational tool that could help address these problems. Participants expressed a preference for a WAP that gives clear, individualised guidance on treatment use, presented in a step-up/step-down approach. Participants also wanted more general information about eczema, its potential triggers, and how to manage problem symptoms.

Conclusion

An eczema WAP may help overcome some of the difficulties of managing eczema, and support families and clinicians in the management of the condition. Further evaluation is needed to determine if the eczema WAP the authors have developed is both acceptable and improves the outcomes for affected children and their families.

Building school health partnerships to improve pediatric asthma care: the School-based Asthma Management Program

PURPOSE OF REVIEW

Children with asthma require care that is seamlessly coordinated so that asthma symptoms are recognized and managed at home and at school. The purpose of this review is to discuss recent consensus recommendations in school-based asthma care.

RECENT FINDINGS

The School-based Asthma Management Program (SAMPRO) provides a widely endorsed framework to coordinate care with schools and consists of four components: establishing a circle of support around the child with asthma; facilitating bidirectional communication between clinicians and schools; comprehensive asthma education for schools; and assessment and remediation of environmental asthma triggers at school. SAMPRO standardizes recommendations for school-based asthma care coordination and provides a toolkit with websites and resources useful for the care of children with asthma in the school setting.

SUMMARY

The review will discuss the need for coordinated school asthma partnerships, the inception and development of SAMPRO, and its vision to improve pediatric asthma care coordination within the circle of support, comprising clinicians, school nurses, families, and communities.

Children with asthma and their caregivers help improve written asthma action plans: A pilot mixed-method study

OBJECTIVE

The objectives of this study were to (a) qualitatively examine caregiver and child feedback about a gold standard written asthma action plan (WAAP), and (b) determine whether having an asthma action plan was associated with child and caregiver self-efficacy in managing an exacerbation.

METHODS

This was a cross-sectional analysis of structured interviews with 22 children with persistent asthma that collected feedback about the WAAP as well as self-efficacy. An analysis of interviews used the constant comparative method to identify themes of child and caregiver statements. Caregivers completed a questionnaire that measured asthma management self-efficacy, barriers to managing asthma, and belief in the treatment efficacy using validated scales.

RESULTS

Approximately 36% of the caregivers reported having a WAAP for their child from their child's pediatrician. Most caregivers stated that having pictures would improve the WAAP, while most children stated that the layout needed to be improved by adding more space between the sections. Caregivers who reported knowing what the asthma action plan was had greater self-efficacy than caregivers who did not (z = -1.99, p = 0.047).

CONCLUSIONS

Re-designing the current WAAP layout and including pictures of inhalers may promote patient understanding. Future research needs to examine if a re-designed WAAP improves asthma management of children with asthma and their caregivers.

Creation and implementation of SAMPRO™: A school-based asthma management program

Clinicians who care for children with asthma have an obligation to coordinate asthma care with the schools. Aside from routine clinical care of asthmatic children, providers must educate the family and child about the need for an asthma treatment plan in school and support the school nurse meeting the needs of the student requiring school-based asthma care. The following article was developed by multiple stakeholders to address this need. It describes the 4 components of the School-based Asthma Management Program (SAMPRO™). SAMPRO™ details elements necessary for the education of children, families, clinicians, and school-based personnel based on a “circle of support” that would enhance multidirectional communication and promote better care for children with asthma within the school setting.

Evaluating asthma websites using the Brief DISCERN instrument

PURPOSE

The primary purpose of this study was to examine the quality of sponsored and unsponsored asthma websites using the Brief DISCERN instrument and to evaluate whether the Health On the Net Code of Conduct (HONcode) logo was present, thereby indicating that the site met the criteria. The Internet is an important source of health information for patients and their families. The primary purpose of this study was to examine the quality of sponsored and unsupported asthma websites. A secondary aim was to determine the readability and reading ease of the materials for each website along with the grade level.

METHODS

We queried seven Internet search engines using the keyword "asthma." The websites were evaluated using the six-item Brief DISCERN instrument and by ascertaining whether the HONcode quality label was present. The websites were also evaluated for readability employing Flesch-Kincaid grade level and Flesch reading ease tools using Microsoft Office Word 2013 software.

RESULTS

A total of 22 unique websites were included in the study. Approximately 68% of the websites reviewed had a Brief DISCERN cutoff score of ≥16. The overall Brief DISCERN scores ranged from 6 to 30, and the mean score was 17.32 (SD =6.71). The Flesch-Kincaid grade level scores ranged from 2.9 to 15.4, and the average reading grade score was 9.49 (SD =2.7). The Flesch reading ease scores ranged from 17 to 82.7, with a mean reading ease score of 53.57 (SD =15.03). Sites with a HONcode quality label had significantly higher Brief DISCERN scores than those without one (t=2.3795; df=20; p=0.02).

CONCLUSION

Brief DISCERN scores revealed that there is quality asthma information for children and their families available on the Internet. The grade level ranged between 2.9 and 15.4 among the websites. However, the mean grade level scores were 9.3-9.89, which is high for the average consumer. Access to accurate information via the Internet, with appropriate readability, may enable pediatric asthma patients and their caregivers to better control and manage asthma.

What might parents read: Sorting webs of online information on vascular anomalies

INTRODUCTION

The internet is increasingly a source of healthcare information utilized by parents, especially in rarer pathologies such as vascular malformations. The quality, validity and thoroughness of these websites is variable and unregulated. The goal of this study was to evaluate the quality and understandability of websites related to vascular malformations.

METHODS

The terms "hemangioma", "vascular malformation", and "vascular anomalies" were searched in Google. The first 30 websites meeting inclusion and exclusion criteria were evaluated. Quality and readability were assessed using the DISCERN criteria and the Flesh-Kincaid Reading Grade Level (FKGL), respectively. Date of last update, HONcode accreditation, and the website category were recorded.

RESULTS

Most websites were owned by academic institutions (n = 19, 63.3%). The mean DISCERN score for all websites was 2.97, or a partially valid source of information on a 1-5 scale. The average reading level estimated by FKGL was grade 12; only one website was scored at less than a grade 9 level. Two websites were HONcode accredited. Of the 18 sites giving an explicit date of last update, 12 (67.7%) had been updated in the previous 12 months.

CONCLUSIONS

Websites relating information about vascular anomalies may not be understandable to the general public, including parents. Health care providers should be cognizant of the quality and availability of such information as it may impact parent perspectives and bias toward treatment options.

The Readability of Electronic Cigarette Health Information and Advice: A Quantitative Analysis of Web-Based Information

Background

The popularity and use of electronic cigarettes (e-cigarettes) has increased across all demographic groups in recent years. However, little is currently known about the readability of health information and advice aimed at the general public regarding the use of e-cigarettes.

Objective

The objective of our study was to examine the readability of publicly available health information as well as advice on e-cigarettes. We compared information and advice available from US government agencies, nongovernment organizations, English speaking government agencies outside the United States, and for-profit entities.

Methods

A systematic search for health information and advice on e-cigarettes was conducted using search engines. We manually verified search results and converted to plain text for analysis. We then assessed readability of the collected documents using 4 readability metrics followed by pairwise comparisons of groups with adjustment for multiple comparisons.

Results

A total of 54 documents were collected for this study. All 4 readability metrics indicate that all information and advice on e-cigarette use is written at a level higher than that recommended for the general public by National Institutes of Health (NIH) communication guidelines. However, health information and advice written by for-profit entities, many of which were promoting e-cigarettes, were significantly easier to read.

Conclusions

A substantial proportion of potential and current e-cigarette users are likely to have difficulty in fully comprehending Web-based health information regarding e-cigarettes, potentially hindering effective health-seeking behaviors. To comply with NIH communication guidelines, government entities and nongovernment organizations would benefit from improving the readability of e-cigarettes information and advice.

Use of a low-literacy written action plan to improve parent understanding of pediatric asthma management: A randomized controlled study

OBJECTIVES

The objective of the study was to determine whether parents who use a low-literacy, pictogram- and photograph-based written asthma action plan (WAAP) have a better understanding of child asthma management compared to parents using a standard plan.

METHODS

A randomized controlled study was carried out in 2 urban pediatric outpatient clinics. Inclusion criteria were English- and Spanish-speaking parents of 2- to 12-year-old asthmatic children. Parents were randomized to receive a low-literacy or standard asthma action plan (American Academy of Allergy, Asthma and Immunology) for a hypothetical patient on controller and rescue medications. A structured questionnaire was used to assess whether there was an error in knowledge of (1) medications to give everyday and when sick, (2) need for spacer use, and (3) appropriate emergency response to give albuterol and seek medical help. Multiple logistic regression analyses were performed, adjusting for parent age, health literacy (Newest Vital Sign); child asthma severity, medications; and site.

RESULTS

217 parents were randomized (109 intervention and 108 control). Parents who received the low-literacy plan were (1) less likely to make an error in knowledge of medications to take everyday and when sick compared to parents who received the standard plan (63.0 vs. 77.3%, p = 0.03; adjusted odds ratio [AOR] = 0.5[95% confidence interval: 0.2-0.9]) and (2) less likely to make an error regarding spacer use (14.0 vs. 51.1%, p < 0.001; AOR = 0.1 [0.06-0.3]). No difference in error in appropriate emergency response was seen (43.1 vs. 48.1%, p = 0.5).

CONCLUSIONS

Use of a low-literacy WAAP was associated with better parent understanding of asthma management. Further study is needed to assess whether the use of this action plan improves child asthma outcomes.

Readability and Content Characteristics of Powdered Infant Formula Instructions in the United States

OBJECTIVES

This study aimed to assess readability characteristics and layout features, including reading grade level, text point size, dimensions (length and width), diagrams, key directions (warnings, proper hygiene, preparation and use, and storage), and compliance to International Code provisions of English-language instructions affixed to a representative sample of brand-name and generic powdered, infant formula containers currently available for purchase in the US.

METHODS

During June 2014, comprehensive Internet searches were conducted to identify brand-name powdered infant formulas currently available for purchase in the US (n = 10). The English-language instruction section affixed to each formula container was evaluated for readability characteristics and layout features, including reading grade level, text point size, dimensions (length and width), diagrams, key directions (warnings, proper hygiene, preparation and use, and storage), and compliance to International Code.

RESULTS

Overall, containers were similar in circumference (50.8 ± 7.3 cm) and height (14.0 ± 0.0 cm) and held an average of 656.0 ± 12.3 g (range 629-663 g) of powdered infant formula. Both Directions for Preparation and Use and Storage Instructions sections had average reading difficulty scores at the college level. Step-by-Step Preparation Directions and Warnings and Safe Handling sections had reading difficulty between the 8th and 9th grade level. All container labels contained three diagrams depicting step-by-step preparation instructions and a feeding chart. Overall, infant formula containers reviewed in our study adhered to compliance to International Code provisions.

CONCLUSIONS

As negative health outcomes are associated with inappropriately prepared infant formula feedings, healthcare providers should routinely query infant caregivers regarding their formula preparation and administration practices.

A web-based educational video to improve asthma knowledge for limited English proficiency Latino caregivers

OBJECTIVES

To evaluate limited English proficiency (LEP) Latino caregiver asthma knowledge after exposure to an educational video designed for this target group.

METHODS

A cross-sectional, interventional study was performed. We aimed to evaluate the post-test impact on asthma knowledge from baseline after exposure to a patient-centered, evidence-based, and professionally produced Spanish asthma educational video. Participants included LEP Latino caregivers of children 2-12 years old with persistent asthma. Enrollment was performed during ED encounters or scheduled through a local community organization. Asthma knowledge was measured with a validated Spanish parental asthma knowledge questionnaire. Differences in mean scores were calculated with a paired t-test.

RESULTS

Twenty caregivers were enrolled. Participants included mothers (100%) from Puerto Rico (75%), with a high-school diploma or higher (85%), with no written asthma action plan (65%), whose child's asthma diagnosis was present for at least 3 years (80%). Mean baseline asthma knowledge scores improved 8 points from 58.4 to 66.4 after watching the educational video (95% CI 5.3-10.7; t(19) = 6.21, p < 0.01). Knowledge improvements were similar across the ED and community groups. Knowledge gains were observed in the areas of ED utilization, medication usage, and activity limitations.

CONCLUSIONS

The developed educational video improved caregiver asthma knowledge for a Latino population facing communication barriers to quality asthma care. Dissemination of this educational resource to LEP caregivers has the potential to improve pediatric asthma care in the United States.

Health Literacy and Preferences for Sources of Child Health Information of Mothers With Infants in the Neonatal Intensive Care Unit

BACKGROUND

Parents of infants hospitalized in the neonatal intensive care unit (NICU) frequently need guidance to prepare them for the care and health promotion of their child after hospital discharge. The health literacy of the parents should be considered so that education can be tailored to meet their needs. It is also important to understand the parents' preferences for how, and from whom, they receive education.

PURPOSE

The purpose of this study was to identify health literacy levels of parents of infants in an NICU and preferences for who they want to provide them with education.

METHODS

An exploratory, descriptive design was used to assess participant health literacy and preferences for obtaining child health information. Only mothers (no fathers) with babies in the NICU were available to complete the survey. Mean participant age was 26.4 years (SD = 6.7).

RESULTS

Participants had a mean Rapid Estimate of Adult Literacy in Medicine, Revised, score of 5.64 (SD = 2.4), indicating a low level of health literacy. Questions regarding when to administer medication were correctly answered by 69% of participants. Proper medication dosage was understood by 92% of participants; however, only 30% were able to correctly convert measurements. One-on-one discussions with a physician were the preferred source of health information for 80% of participants.

IMPLICATIONS FOR PRACTICE/RESEARCH

The current exploratory study provides new information that will help inform the development of future studies and increase awareness of nurses regarding health literacy and the specific types of skills for which parents need the most help.

Feasibility of Picture-Based Asthma Medication Plans in Urban Pediatric Outpatient Clinics

Picture-based Asthma Action Plans show promise for overcoming parental literacy barriers and improving child asthma outcomes, but it is uncertain how parents respond to pictures of specific medications, which may be particularly important for improving disease self-management. Thus, we assessed parent attitudes toward an asthma-related picture-based medication plan (PBMP) in an urban academic pediatric clinic and examined attitudes by literacy level. Surveys were administered to a convenience sample of parents of children presenting to an urban pediatric pulmonary clinic for asthma consultation between March and August 2011. The Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF) was administered to parents. Parents indicated their level of agreement with 9 statements on the potential usefulness of the PBMP: (1) before being shown a PBMP; and (2) after seeing the doctor. McNemar's tests showed that the proportion of high-literate parents (≥9th grade reading level) who endorsed the potential benefits of the PBMP after the clinical encounter was significantly higher than before the clinical encounter. A high proportion of low-literate parents (<9th grade reading level) consistently endorsed the PBMP before and after the clinical encounter. Among a diverse sample seen in an urban asthma clinic, parents of all literacy levels endorse PBMPs as useful, especially after using them in clinical encounters.