Physiotherapy Health Education Literature

This paper describes a survey of the reading levels and design of leaflets distributed by a physiotherapy service. Physiotherapists design health education leaflets to inform patients and reinforce recommendations made in a session of therapy. The effectiveness of these leaflets depends largely on whether patients can read and understand them. A questionnaire survey in physiotherapy departments spanning two National Health Service trusts in Southampton showed that while physiotherapists were generally happy with the accuracy of their leaflets, they were less satisfied with their appearance. An analysis using Gunning's Fog Index Formula demonstrated that only 33% of the leaflets were written at or below the recommended reading level for health education literature, ie grade 9. The average reading level of the leaflets was grade 10. The survey underlines the need for physiotherapists to review the health information literature they are giving to patients. If they want patients to use it to inform and motivate themselves and to change health behaviours, then the written information must be attractive, readable and easy to understand. Suggestions are made for improving the quality and readability of leaflets.     

Assessing the readability statistics of national consent forms in the UK

Introduction: When obtaining consent for an invasive procedure, the patient needs to understand what is happening to them in broad terms. Best medical practice advocates that written consent is given to acknowledge patient agreement. Across the UK, the Department of Health has provided standard consent forms for obtaining consent in all situations. Potentially these written sources of information may not be comprehended by patients and thus invalidate consent. Method: Consent forms were assessed by the Flesch readability and Flesch‐Kincaid grade formulae and compared with the national reading age, the recommended level for patient medical information, three newspaper articles and a journal article. Results: The consent forms have acceptable statistics [average Flesch readability 61.1 (range 57.2–66.1) and Flesch‐Kincaid grade 7 (range 6.3–8)]. This grade, however, is above the recommended level of patient health information (Flesch‐Kincaid grade 6). When the patient statements are isolated the reading statistics worsen [average Flesch readability 52.6 (range 41–62.6) and Flesch‐Kincaid grade 9.6 (range 7.9–11.1)]. Conclusion: Consent forms should be used as adjuncts to detailed conversations, describing what a procedure involves to ensure that a patient understands, in broad terms, what is happening to them. The patient’s statement section of the form may be being written at a level above patient comprehension currently and thus could invalidate any consent given. We would advocate a documented conversation with patients to ensure they have a broad understanding of the procedure and using the consent form as an adjunct to this discussion. The patient’s statement section should be re‐written to avoid invalidating consent.     

Analysis of patient information leaflets provided by a district general hospital by the Flesch and Flesch-Kincaid method

Introduction: Patient information leaflets (PILs) remain the most frequently used sources of medical information. There is a concern that the reading age of these leaflets may exceed patient comprehension, thus negating their beneficial effect. The ‘Flesch Reading Ease’ and the ‘Flesch–Kincaid grade level’ are established methods for providing reliable and reproducible scores of readability. Method: All available hospital PILs (171) were assessed and divided into 21 departments. Microsoft Word was used to provide Flesch and Flesch–Kincaid readability statistics and compared against the national reading age and the recommended level for provision of medical information. Results: The average Flesch readability of all of the hospital’s PILs is 60, with a Flesch–Kincaid grade of 7.8 (12–13 years old). There is considerable variation in the average readability between departments (Flesch readability 43.8–76.9, Flesch–Kincaid 5.4–10.2). The average scores of two departments have PILs scores suitable for patient information. Conclusion: Although our PILs were well laid out and easy to read, the majority would have exceeded patient comprehension. The current advice for provision of NHS information does not highlight the importance of a recommended reading level when designing a PIL. Potentially a wide group of patients are being excluded from the benefits of a PIL.     

Readability of printed patient information for epileptic patients

BACKGROUND: Written information can be a valuable tool in patient education. Studies evaluating written information for various disease states have frequently demonstrated that the majority of literature is written at a readability level that exceeds that of the average patient, and it has been recommended that written communications for adult patients should be provided at a fifth-grade level or lower. OBJECTIVE: To assess the readability of printed patient information available to patients with epilepsy. METHODS: Samples of written patient information (n = 101) were obtained from various sources. The information was classified based on source, content, and intended audience, and readability was assessed using the Flesch Reading Ease Score (FRES) and Flesch-Kincaid Grade Level (FKGL) score. RESULTS: The mean FRES and FKGL score for all samples were 50.2 and 9.4, respectively. Significant differences were observed in both the FRES and FKGL score of material obtained from different sources; however, no differences were observed when material was analyzed according to content. The mean FRES and FKGL score for materials intended for adults were 49.6 and 9.5, respectively. In comparison, mean FRES and FKGL scores for materials intended for children/adolescents were 78.9 and 5.3, respectively. CONCLUSIONS: The majority of information tested was written at a level that exceeds the reading ability of many patients. The information intended for children is actually written at the appropriate level for an adult. Efforts should be taken to develop written teaching tools that target low-level readers, especially for a disease state that affects many children.     

The suitability of United States Pharmacopoeia Dispensory Information psychotropic drug leaflets for urban patients with limited reading skills.

Although considerable research exist on the readability of patient education materials, few studies have focused on the efficacy of information drug leaflets used for psychopharmacology education of patients with limited reading skills. The purpose of this investigation was to evaluate the suitability of United States Pharmacopoeia Dispensary Information (USP-DI) drug leaflets (N = 42) for educating urban in-patients at a psychiatric unit using measurement criteria of the Suitability Assessment for Materials (SAM) instrument. The findings showed the USP-DI information drug leaflets were unsuitable as an educational tool for psychiatric in-patients with poor reading ability.     

Knowledge deficit in the ophthalmic surgical patient.

This case history illustrates some important aspects of the informational needs of ophthalmic surgery patients. As is true with many ophthalmic patients, this patient had a relatively high level of anxiety regarding his potential loss of vision postoperatively. This concern is magnified in a monocular patient. The nurse must help these patients put this concern in the proper perspective by providing accurate information. The nurse who performs such extensive preoperative teaching takes on a role that entails a great deal of responsibility. A planned program of information with written objectives and an outline of the important information to include will help the nurse provide a high level of care in meeting the knowledge needs of the patient. It is not necessary, or even desirable, to develop a plan for each individual patient. A written outline of important and necessary information for each type of ophthalmic surgical procedure provides a means of assuring that the teaching plan is complete and accurate. The information in the teaching plan should be validated by other physician and nurse colleagues. A written plan can save time once it is developed, because the nurse can follow the standard plan, modifying the presentation to meet each patient's specific needs as necessary. The patient indicated feeling somewhat overwhelmed with information when faced with his ophthalmic surgery. It is very important to ensure that the patient and appropriate significant others get both verbal and written information in these situations. The written information gives the patient and his or her family a reference to use when they return home and begin to assimilate more of the information given to them by the nurse. The patient in this case history and his wife both referred to the written instructions several times before and after the operation to verify certain information. The written materials presented information at an appropriate reading level and had large well-spaced print. Repetition (whether verbal or in written format) is important because it reinforces important aspects of the necessary information. The nurse at the surgical facility repeated the postoperative requirements to the patient and his wife before they left the center and made sure that they had the written instructions as well. The nurse demonstrated the necessary motor skills and gave the patient and his wife the opportunity to return the demonstration.     

A qualitative evaluation of information leaflets for gastroscopy procedure

Written information sent to patients prior to diagnostic gastroscopy is an important part of the process of informing and preparing them for the procedure. Yet there is ample evidence in the literature that information leaflets do not measure up to the required standard. In this study, information leaflets from a random sample of seven hospitals in Northern Ireland that carried out gastroscopy as a day procedure were evaluated using a checklist of items recommended by the British Society of Gastroenterology (BSG) for inclusion in leaflets for patients undergoing diagnostic gastroscopy. The results showed that the number of written materials sent to patients prior to the procedure varied between units. There were inconsistencies in the information given by the same unit, and overall, there was a lack of vital information in most of the leaflets. Some of the information was confusing and ambiguous. The potential risk of the procedure was explained in only one of the leaflets. Patients' right to choose to have a mild sedative was not made clear in most of the leaflets. More should be done to address these gaps and inconsistencies in the written information provided to patients prior to gastroscopy.     

How nurses can develop good patient information leaflets

Nurses are increasingly involved in the development of patient information leaflets. Producing good patient information is a team effort between professionals and patients. Involve your patients, set clear goals and provide the very best information. Present the information as clearly and positively as possible. This article outlines the importance of a clear purpose, good information and accessible language. Guidance on how to achieve these things is provided, along with tips for improving the readability of your document. Details of online resources and training are also included.     

Developing low-literacy health education materials for women

Research has consistently shown that people absorb information significantly better when written information is provided in conjunction with verbal explanations. Despite this, studies also show that many written health education materials do not have readability levels that are appropriate for women who have low literacy skills. This article summarizes the process and essential considerations, such as content of the material, readability, layout, design, culture, language, and medium of delivery in the development of low-literacy health education materials.     

How informed is consent in sham-controlled trials of acupuncture?

OBJECTIVES: We sought to investigate whether, and if so, how published sham-controlled trials of acupuncture report on the information given to patients about true and sham interventions. We asked acupuncture therapists to provide original patient information leaflets in order to study how interventions were described in more detail. METHODS: Forty-seven (47) published sham-controlled trials of acupuncture collected for a systematic review on sham techniques were screened to determine whether they reported on information given to patients about study interventions; any such information was extracted. We contacted authors of published studies and other researchers in the field and asked them to provide copies of original patient information leaflets. Information given to patients about true and sham interventions was extracted. RESULTS: Ten (10; 21%) of the 47 published studies included some information on how patients were informed. None of these studies appear to have used the term "sham" or "placebo" and most appear to have suggested that two types of acupuncture were compared. In the 16 original patient information leaflets obtained, the way patients were informed varied greatly: 7 leaflets explicitly included words such as "sham," "placebo," or "dummy." Others described the control intervention as not meeting all criteria of acupuncture. Finally, one group of studies simply suggested that different types of acupuncture were being compared. CONCLUSION: Our results indicate that (1) only a minority of published trials report on information given to patients about true and sham interventions and (2) that information strategies vary considerably and are often not fully explicit. This has not only ethical relevance but also might influence results of trials.     

Development of a teaching tool for women with a gynecologic malignancy undergoing minimally invasive robotic-assisted surgery

Women undergoing minimally invasive robotic-assisted surgery for a gynecologic malignancy have many questions and concerns related to the cancer diagnosis and surgery. The provision of information enhances coping with such illness-related challenges. A lack of print materials for these patients prompted the creation of a written teaching tool to improve informational support. A booklet was developed using guidelines for the design of effective patient education materials, including an iterative process of collaboration with healthcare providers and women who had undergone robotic-assisted surgery, as well as attention to readability. The 52-page booklet covers the trajectory of the woman's experience and includes the physical, psychosocial, and sexual aspects of recovery.     

Writing and designing readable patient education materials.

Functional illiteracy is a problem often overlooked by nurses. Although the average adult in the United States cannot read above the eighth-grade level, most patient education materials are written on a high-school or college reading level. If patients cannot read educational materials, then there is little hope of them using or understanding the information. Strategies for improving the readability of education materials specific to the needs of nephrology patients are discussed in this article.     

The quality and management of written information presented to women undergoing hysterectomy

• ? A study of a random sample of hospitals in England that provide information leaflets for women undergoing hysterectomy indicates a large variation in quality.
• ? In general, the findings reveal that written information for patients is given a relatively low priority.
• ? Production and dissemination of information for hysterectomy patients is somewhat ad hoc.
• ? It is not clear that any evaluation of the leaflets has been conducted to prove the efficacy of the available literature.
• ? While the majority of leaflets include information deemed essential by past hysterectomy patients, the presentation of the recovery process often implies no control for the patient, and conceives normality with a narrow perspective about what healthy behaviour means for women. The provision of a specific timetable for resumption of housework duties in 65% of the leaflets is a case in point.
• ? On the basis of the results of the survey, recommendations are made concerning the improvement of the standard of patient information leaflets.

     

Need for appropriate written information for patients,with particular reference to head and neck cancer

Patients need and want written information. There is evidence that giving comprehensible information increases overall satisfaction with the care given by healthcare professionals. This paper provides a review of the literature on patients' need for appropriate information, with particular reference to head and neck cancer, based on searches of electronic databases. Head and neck cancers are among the least common cancers in the UK but these patients have very specific and great needs. Written information is a cost-effective intervention that complements verbal advice given by healthcare professionals. Evidence suggests that patient information leaflets are poor and are in language that is difficult for the public to understand. Considerable time, effort and user involvement are required to produce acceptable and appropriate information leaflets for patients.     

Readability of printed educational materials used to inform potential and actual ostomates

• ? This paper is primarily concerned with the use of readability formulas to determine the reading ease of printed education materials (PEMs) given to ostomy patients. Whilst the particular clinical focus is stoma care nursing, the content is relevant to all nurses who use printed text to inform their patients. PEMs have significant advantages in conveying information compared with verbal presentations alone.
• ? Methods to calculate readability using the Flesch, FOG and SMOG readability formulas are described. Presentation factors that affect readability are briefly reviewed, including use of ‘white space’, font size and paper colour. The problem of functional illiteracy and the need for indirect assessment of patient literacy are discussed.
• ? PEMs in use are often found to be difficult to read. Stress is identified as a potential factor in further reducing a patient's ability to deal with information.
• ? Three commercially available PEMs are evaluated for ease of reading and their score on the FOG index indicates that only about 40% of the UK population would understand them.
• ? Nurses are advised to evaluate the readability of their PEMs and to assess indirectly the literacy of their patients, so that they can more sensitively match PEMs to patient ability and need.

     

Quality of patient information leaflets for Down syndrome screening: A comparison between the UK and Thailand

Prenatal screening tests can help to estimate the possibility of a pregnant woman having a baby with trisomy 21 (Down syndrome). As these tests are optional, it is essential that women are provided with appropriate verbal and written information to enable them to make an informed choice. In this study, we assessed the content and quality of Down syndrome screening information leaflets used by health professionals to provide information to pregnant women in the UK (26 leaflets) and Thailand (11 leaflets). We collected leaflets from health institutions and the Internet, and compared the topics covered in each one against recommendations for patient information on this topic. We also assessed the quality of each leaflet using the DISCERN Genetics tool. While the quality‐rating score of the UK leaflets was significantly higher than the Thai leaflets, none of the leaflets included all the recommended topics; some contained erroneous material. In both countries, the quality of information can be improved to provide accurate information to women and their partners, which is essential to ensure prospective parents can make informed choices during pregnancy.     

Readability of Invasive Procedure Consent Forms

Background

Informed consent is a pillar of ethical medicine which requires patients to fully comprehend relevant issues including the risks, benefits, and alternatives of an intervention. Given the average reading skill of US adults is at the 8th grade level, the American Medical Association (AMA) and the National Institutes of Health (NIH) recommend patient information materials should not exceed a 6th grade reading level. We hypothesized that text provided in invasive procedure consent forms would exceed recommended readability guidelines for medical information.

Materials and methods

To test this hypothesis, we gathered procedure consent forms from all surgical inpatient hospitals in the state of Rhode Island. For each consent form, readability analysis was measured with the following measures: Flesch Reading Ease Formula, Flesch–Kincaid Grade Level, Fog Scale, SMOG Index, Coleman–Liau Index, Automated Readability Index, and Linsear Write Formula. These readability scores were used to calculate a composite Text Readability Consensus Grade Level.

Results

Invasive procedure consent forms were found to be written at an average of 15th grade level (i.e., third year of college), which is significantly higher than the average US adult reading level of 8th grade (p < 0.0001) and the AMA/NIH recommended readability guidelines for patient materials of 6th grade (p < 0.0001).

Conclusion

Invasive procedure consent forms have readability levels which makes comprehension difficult or impossible for many patients. Efforts to improve the readability of procedural consent forms should improve patient understanding regarding their healthcare decisions.     

Comparative evaluation of patient information leaflets by pharmacists,doctors and the general public

This study was undertaken to compare and contrast the views of pharmacists, general practitioners (GPs) and the general public on the value or otherwise of pharmacy-generated patient information leaflets. All three groups perceived these leaflets to be useful and an aid to improving compliance. Concerning the information included in leaflets, GPs rated the inclusion of a section on side-effects as being the least important, whilst pharmacists and the general public rated information on the storage of medicines as being least important. Pharmacists' estimates on what percentage of patients actually read leaflets were significantly lower than estimates by the general public. General practitioners and pharmacists generally concurred on the types of patients for whom leaflets are considered unsuitable, although a significantly higher percentage of pharmacists than GPs identified unsuitable patients. There were reservations by the pharmacists concerning the cost-effectiveness of leaflet facilities and on the value of leaflets compared with verbal counselling. The general public expressed the view that a leaflet facility would affect their choice of pharmacy and that they would be prepared to wait an additional short time to receive such a leaflet. Almost all GPs thought that it was in the patient's best interest to receive an information leaflet.