Research Overview

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Slide 1

This section provides a brief overview of some of the research regarding the design of printed patient education materials. I will share some of the resources I used in the development of this presentation and toolkit and provide a rationale for why I developed the design readability scorecard.

Slide 2

While we are focusing on using printed patient education materials, I would be amiss if I did not begin by stressing what several research studies have shown to be true: to be most effective, printed education materials should be used with verbal instruction and education. And the opposite of that is also true. Verbal health information and education that is followed up with printed information greatly increases knowledge retention and understanding. Research also shows that good information, both verbal and written, improves patient satisfaction. Patients who report higher satisfaction also report higher levels of trust and are more likely to comply with recommendations and adhere to treatment.

Slide 3

Most patient education is done verbally. By that I mean the majority of what we want patients to know about their health, about a particular disease or condition, a treatment, medication, test, screening, or procedure, is done by talking to the patient. This is most often done by the doctor, a nurse, a patient educator, or other member of the health care team. Verbal communication is essential. Printed patient education materials should never replace verbal communication. Instead, printed materials provide additional, more in-depth information, and reinforce what is verbally communicated to the patient. Printed education materials and information serve as a source of future reference and can be shared with family members and other care givers. Patient education materials that are written well and designed well encourage and empower patients to better self-manage their health, share in informed decision-making, and become active participants in their care.

Slide 4

The average adult in the United States reads at about the sixth to eighth grade reading level, even if their total number of years of education far exceeds that grade level. This is often surprising to most people who hear this for the first time. We tend to equate reading level with years of education and we expect someone with a high school diploma to read at the twelfth grade level. However, reading skill varies among individuals who have completed the same number of years of education. Also, reading is a skill that must be retained. A college student may be able to read and understand information that is written at a fourteenth or fifteenth grade level. But after college, unless that student continues to read books and articles at that level, his reading skills will regress. A typical newspaper is written at the tenth grade level. USA Today is written at about the eighth grade level. Most books of the New York Times list of bestsellers are written at the eighth to tenth grade level. We read mostly for information and entertainment, and we usually select reading material that is written at a level that is comfortable for us.

Slide 5

Teaching patients with low literacy skills by Doak, Doak and Root, now out of print, remains a seminal text and resource for health care professionals and educators. Armed with a magnitude or research, and before data from the National Adult Literacy Survey conducted in the early 90’s were widely available, the authors were recommending that health education materials be written at the sixth to eight grade level. They and other researchers also told us that most health information is written at the tenth grade level and often above, far exceeding the reading skills of most Americans. A second national survey, the National Assessment of Adult Literacy, which for the first time included an assessment of health literacy in America, and several research studies helped us focus on the readability of our printed patient education materials. Despite all the research, the tools and recommendations, we still often produce patient education handouts that exceed the reading level for most of our patients. But we continue to make strides in improving these education materials. While we focus on the words we use, applying the recommendations of plain language, we can easily overlook another important aspect of readability.

Slide 6

The design, layout and format of printed patient education materials is just as important as the words we use, and can equally affect readability in both positive and negative ways. You can create a document that is written in plain language and even use a readability formula such as SMOG, FOG or Fry to confirm it is written at the sixth grade level; however, if the font is too small, if the document does not include white space, or the text is not grouped into manageable sections, the document can be difficult to read. If a document looks difficult to read, if it’s heavy on text, with long lines of words in small print that stretch across the width of the page, it is likely that patients will not even attempt to read it. Of course, the reverse is also true. You can have a well designed document that looks easy to read, but if contains long sentences, jargon, and medical terms and concepts that are not clearly defined or explained, the document can be difficult to read. How a document is written, that is the words and style we use, together with the design and format of the document determine whether or not patients perceive that it is easy to read and understand.

Slide 7

In the key terms and definitions section of this toolkit, we defined and explained the concept of universal design. The goal is to develop documents that the majority of our patients can use, without having to create several versions of the same document. If most Americans read at the sixth to eighth grade level, and if most people prefer information written at that level despite their years of education attained, it makes sense to produce documents written at this level. It will be appropriate for the majority of your patients. There may be 10 to 20 percent of patients who may need a specialized handout. Older patients often have vision problems, so you might need to make versions of your handouts using a larger font. Or you may have patients who do not speak or read English well or at all, and you should make appropriate accommodations by having your patient education materials translated. The design recommendations in this toolkit are for universal design. There is research as well as tools and resources that can assist you in developing specialized documents customized for your patients that are not included in the 80 to 90 percent for whom universally designed materials are appropriate. Also, we are focusing on printed patient education handouts. Different recommendations often apply to other mediums. Web based documents are a good example. Designing web based education materials and web pages is outside the scope of this toolkit. However, I have posted some links to resources for those who want more information about designing documents for the Internet.

Slide 8

Here is the reference citation to Teaching Patients with Low Literacy skills and other resources I consulted while developing this presentation and toolkit.

Slide 9

There are a number of manuals, handbooks, and guides to writing and designing patient education materials. Most, including resources from the CDC, CMS and NIH are in the public domain. I have included them as links in the “additional resources you might find helpful” section on the right side of this Web page. The Health Literacy Style Manual, prepared for Covering Kids & Families, a national program supported by the Robert Wood Johnson Foundation, is an excellent resource.

Slide 10

Despite all of the available resources for writing and designing patient education materials, I found variation in the recommendations, and some, to be quite honest, were downright vague and not very helpful. For example, I consulted ten different resources looking for recommendations about white space, and in particular, guidelines for setting document margins. I found ten different answers. Some resources offered specific recommendations, such as “leave at least ½ to 1 inch of white space between the margins of the page and between columns.” Others only offered vague suggestions like “allow wider margins.” Still other handbooks and guides didn’t offer any recommendations or suggestions about margins and white space at all. For this toolkit, then, I looked at the available research and resources and collated the best recommendations based on the evidence. Because of the variation in recommendations, design of documents is often left to the subjective judgment of the writer or graphic designer. However, there are key design elements that do impact the readability of printed patient education materials and I have included them in this toolkit along with illustrative examples and design strategies proven to have a positive impact on readability. At the same time I wanted to develop a design evaluation tool beyond a simple checklist or list of recommendations. Just as readability formulas and tools like FOG, SMOG and Fry provide a score or grade level for the text, I wanted to develop a design evaluation tool that converts what are often subjective judgments into a quantifiable, numeric score that has meaning, can be validated, and can provide a standard for evaluating and comparing documents based on design. The design score, together with a score from a readability formula, provide a more complete evaluation and help ensure that our patient education documents are both written and designed to be “easy to read.”

Slide 1

Part 3 Research Overview

Slide 2

Research Overview Verbal patient education should always be accompanied by written information, for it enhances the clients' understanding of what was taught and helps clients manage their own health care. Gannon W, Hildebrandt E. A winning combination: Women, literacy, and participation in health care. Health Care Women Int 2002;23:754-760. Provision of both verbal and written health information significantly increased knowledge and satisfaction scores. Johnson A, Sandford J, Tyndall J. Written and verbal information versus verbal information only for patients being discharged from acute hospital settings to home. Cochrane Database Syst Rev. 2003;(4):CD003716.

Slide 3

Research Overview Research done over the past few decades has demonstrated that verbal patient education should always be accompanied by written information, for it enhances the clients' understanding of what was taught and helps clients manage their own health care. Gannon W, Hildebrandt E. A winning combination: Women, literacy, and participation in health care. Health Care Women Int 2002;23:754-760.

Slide 4

Research Overview The average adult in the United States reads at about the sixth to eighth grade reading level, even if their total number of years of education far exceeds that grade level. Wilson FL, Racine E, Tekieli V, Williams B. Literacy, readability and cultural barriers: Critical factors to consider when educating older African Americans about anticoagulation therapy. J Clin Nurs 2003;12:275-282.

Slide 5

Research Overview It is recommended that health education materials developed for the general public should not exceed sixth to eighth grade levels. Doak C, Doak L, Root J. Teaching patients with low literacy skills, 2nd ed, JB Lippincott Company, New York 1996. The vast majority of health education materials are written at readability levels that are far above the average person's ability to comprehend (usually at least four grades higher than average readability). Dowe MC, Lawrence PA, Carlson J, Kerserling TC. Patients' use of health teaching materials at three readability levels. Appl Nurs Res 1997;10:86-93.

Slide 8

Research Overview Albright J, de Guzman C, Acebo P, Paiva D, Faulkner M, Swanson J. Readability of patient education materials: implications for clinical practice. Appl Nurs Res. 1996;9:139–143. Bernier MJ. Developing and evaluating printed education materials: a prescriptive model for quality. Orthopaedic Nurs. 1993;12:39–46. Doak CC, Doak LC, Root JH. Teaching Patients with Low Literacy Skills. 2nd ed. Philadelphia: J.B. Lippincott; 1996. Ekstrom I. Printed materials for an aging population: design considerations. J Biocommun. 1993;20:25–30. North G, Margree G, Roe M. Guidelines for producing patient information literature. Nurs Stand. 1996;10:46–48.

Slide 10

Research Overview Simply Put: Tips for creating easy-to-read print materials (CDC) - "Leave at least 1/2 to 1 inch of white space between the margins of the page and between columns." [page 19] Principles for Clear Health Communication: A Handbook for Creating Patient Education Materials That Enhance Understanding and Promote Health Outcomes (Pfizer) - Under the "Make It Look Easy to Read" they suggest, "Allow wider margins." [page 35] Clear & Simple: Developing Effective Print Materials for Low-Literate Readers (National Cancer Institute) - No mention of margins in their recommendations.

Summary: An overview of the research and resources used in the development of the Improving Readability by Design toolkit.

Tags: health communications literacy patient education document design readability

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