Evaluation of Printed Health Education Materials Questions

Quantitative Study Critique- 75 points possible The purpose of this assignment is to develop skills in reviewing and

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appraising research articles. Specific details are considered to determine quality, utility, and evidence. Review Chapter 4 in: Polit, D. F., & Beck, C. T. (2018). Essentials of nursing research: Appraising evidence for nursing practice (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. PLEASE USE THIS TEMPLATE for the assignment – save with your last name and submit in Canvas. Direct quoted material from the article may be used to help explain answers and identify components (must include article page number). Please address all questions – briefly with simple items, phrases, or (if required) a sentence or two. If a yes/no question – please answer as appropriate – if not applicable, please state – not applicable. List references ONLY IF other than the article being reviewed or the course text. Helpful strategy – first view the critique template – to have an idea of what items to keep in mind when reading the article. 1. APA citation (2 points possible) 1.1. Provide the reference (authors, year, title, volume, issue, pages, doi) in correct APA format: (use italics where appropriate, etc.) — (2 pt.) 2. Introduction: Problem and Purpose (3 points possible) 2.1 Is the problem clear, precise and well defined? Briefly identify. literature review/ (1 pt.) 2.2 Is a good argument made for the importance of the problem to clinical practice, research, theory, or knowledge and policy development? Briefly explain. (2 pts) 3.Introduction: Background/ Literature Review (5 pts possible) 3.1 How many articles in the background /literature review are within and after five years of the article’s publication date? (Often in published studies, the literature review is not a separate section titled Literature Review, but a literature review is included in the Introduction or Background section.)(1 pt) 3.2 What is the publication date range of the background/literature review articles? (1 pt.) 3.3 From what type of sources (studies, relevant organizations, media)? (1 pt.) 3.4 Are the current gaps in knowledge clearly presented? Briefly explain? (note: typically related to the purpose for the study) (2 pt.) 4. Introduction: Conceptual/theoretical framework Research Questions or Hypotheses (5 points possible) 4.1 Is a Research Question or PICO Question presented? If yes, please include here: (1 pt.) 1 Quantitative 19SU 4.2 Is a Hypothesis presented? If yes, please include here: (1 pt.) 4.3 Is a Theoretical or Conceptual Framework presented? If yes, please include here: (1 pt.) 4.4 What is the Main overall topic (in a broad sense) – i.e. childhood obesity, surgical site infections, medical error? (2 pt.) 5. Method: Protection of Human Rights (8 pts possible l) 5.1 Was the study approved by an IRB? (1 pt.) 5.2 5.3 What appropriate procedures were used to safeguard the rights of all study participants? Explain. (3 pts) Were any vulnerable populations used in the study? If yes, who? (2 pt.) 5.4 What risks may subjects be exposed to while participating in the study? (2 pt.) 6. Method: Research Design (11 pts possible) 6.1 What was the type of quantitative research design used? (i.e. RCT, cross sectional, retrospective analysis, cohort study?) (3 pts) 6.2 Is there an Independent Variable(s) (Intervention)? If yes, Identify here: (3 pt.) 6.3 Is there a Dependent Variable(s) (outcome)? If yes, Identify here: (3 pt.) 6.4 Is there a control group (experimental design)? If yes, Identify here: (1 pt.) 6.5 Is there a comparison group (non-experimental design)? If yes, Identify here: (1 pt.) 7. Method: Population and Sample (11 pts possible) 7.1 Who or what (if the sample includes material items) is identified as the target population/item? (2 pts) 7.2 How were the samples chosen (sampling method: i.e. randomly, convenience sampling, etc..)? (3 pts) 7.3 How large was the sample? (1 pt.) 7.4 What were the sample inclusion criteria and exclusion criteria? (2 pt.) 7.5 Did any of the participants drop out (attrition)? If yes, was it explained why (please share)? (1 pt.) 8. Method: Data collection and Measure (11 pts possible) 2 Quantitative 19SU 8.1 How were data collected? (3 pts) 8.2 What instruments or tools were used to collect data? (Did the researchers use already designed tools/instruments/questionnaires/ lab or x-ray results OR design and build their own?) Identify instruments by full title (not abbreviations). (3 pts) 8.3 Were the instruments reliable and valid? (Review your text for how instrument reliability and validity are established.) Provide evidence for your response. (2 pts) 8.4 Were the data collected in a way that decreased bias? Explain. For example, was the staff collecting data appropriately trained, or inter-rater reliability addressed? Explain. (3 pts) 9. Results: Data Analysis (4 pts possible) 9.1 Was a statistician or statistical software program (SPSS, SAS?) used for data analysis? (1 pt.) 9.2 Were these methods used appropriate for the study? Briefly explain how? (consider the aim of the study: to describe, compare/difference, or explore relationship/correlation) (3 pts) 10. Discussion: Interpretation of the Findings (6 pts possible) 10.1 What were the major findings presented? Briefly Discuss. (3 pts) 10.2 Were tables and figures used? (1 pts) 10.3 Were all research questions/hypotheses discussed? (2 pts) 11. Discussion: Limitations (4 pts possible) 11.1 Did the researchers discuss the limitations and strengths of the study? Briefly What were they? (3 pts) 11.2 Were there other limitations that you recognized? (1 pts) 12. Discussion: Implications/Recommendations (5 pts possible) 12.1 Do the conclusions accurately reflect the data? Briefly explain. (2 pts/) 12.2 Are the implications for practice clearly presented? Briefly Explain (1 pts) 12.3 Are suggestions for future research clearly presented? Briefly Explain (1 pts) 12.4 How do you see this research useful in HC? (1 pts) List references ONLY IF other than the article being reviewed or the course text. 3 Quantitative 19SU CLINICAL SCHOLARSHIP Evaluation of Printed Health Education Materials for Use by Low-Education Families Lesa Ryan, BS1 , M. Cynthia Logsdon, PhD, WHNP-BC, FAAN2 , Sarah McGill, BS3 , Reetta Stikes, MSN, RNC-NIC, CLC4 , Barbara Senior, BSN, MBA, RN5 , Bridget Helinger, MSN, ARNP, ACNP-BC, CCRN6 , Beth Small, BSN, RN, OCN7 , & Deborah Winders Davis, PhD8 1 Medical Student, University of Louisville, School of Medicine, Department of Pediatrics, Louisville, KY 2 Professor, University of Louisville, School of Nursing, and Associate Chief of Nursing for Research, University of Louisville Hospital/James Graham Brown Cancer Center, Louisville, KY 3 Medical Student, University of Louisville, School of Medicine, Louisville, KY 4 Advanced Practice Educator, Center for Women and Infants, University of Louisville Hospital/James Graham Brown Cancer Center, Louisville, KY 5 Clinical Nurse Manager, Stroke ICU, University of Louisville Hospital/James Graham Brown Cancer Center, Louisville, KY 6 Advanced Practice RN, Stroke Services, University of Louisville Hospital/James Graham Brown Cancer Center, Louisville, KY 7 Registered Nurse Clinician, University of Louisville Hospital/James Graham Brown Cancer Center, Louisville, KY 8 Professor, University of Louisville, School of Medicine, Department of Pediatrics, Louisville, KY Key words Health literacy, patient education, health communication, suitability of materials, reading level Correspondence Dr. Deborah Winders Davis, 571 S. Floyd Street, Suite 412, University of Louisville, Department of Pediatrics, Child Development Unit, Louisville, KY 40202. E-mail: deborah.davis@louisville.edu Accepted: January 22, 2014 doi: 10.1111/jnu.12076 Abstract Purpose: Millions of adults lack adequate reading skills and many written patient education materials do not reflect national guidelines for readability and suitability of materials, resulting in barriers to patients being partners in their own health care. The purpose of this study was to evaluate commonly used printed health materials for readability and suitability for patients with limited general or health literacy skills, while providing easy recommendations to health care providers for how to improve the materials. Methods: Materials (N = 97) from three clinical areas that represented excellence in nursing care in our organization (stroke, cancer, and maternal-child) were reviewed for a composite reading grade level and a Suitability Assessment of Materials (SAM) score. Results: Twenty-eight percent of the materials were at a 9th grade or higher reading level, and only 23% were 5th grade or below. The SAM ratings for not suitable, adequate, and superior were 11%, 58%, and 31%, respectively. Few materials were superior on both scales. The SAM scale was easy to use and required little training of reviewers to achieve interrater reliability. Conclusions: Improving outcomes and reducing health disparities are increasingly important, and patients must be partners in their care for this to occur. One step to increasing patient understanding of written instructions is improving the quality of the materials in the instruction for all patients and their families, especially those with limited literacy skills. Clinical Relevance: Using materials that are written in a manner that facilitates the uptake and use of patient education content has great potential to improve the ability of patients and families to be partners in care and to improve outcomes, especially for those patients and families with limited general literacy or health literacy skills. According to the National Adult Literacy Study, over 40 million adults are functionally illiterate and another 50 million have insufficient reading skills (Kirsch, Jungeblut, Jenkins, & Kolstad, 2002). In addition to poor gen218 eral literacy skills, others have shown that 22% of adults have only basic health literacy skills and 14% are below basic levels of health literacy (Kutner, Greenberg, Jin, & Paulsen, 2006). Poor health literacy skills have Journal of Nursing Scholarship, 2014; 46:4, 218–228. C 2014 Sigma Theta Tau International Suitability and Readability of Materials Ryan et al. been associated with less positive health decision making (James, Boyle, Bennett, & Bennett, 2012; Weiss, 1999), adverse health outcomes (DeWalt, Berkman, Sheridan, Lohr, & Pignone, 2004; Edwards, Wood, Davies, & Edwards, 2012), increased emergency care utilization (Omachi, Sarkar, Yelin, Blanc, & Katz, 2013), greater risk for hospitalization (Baker, Parker, Williams, & Clark, 1998), higher annual healthcare costs (Baker et al., 1998; Weiss, 1999, 2007), and lack of adherence to instructions (Smith, Brice, & Lee, 2012). Individuals with chronic health conditions who have limited health literacy have greater severity in symptoms, have poorer health-related quality of life, and feel more helpless than their more literate counterparts, even after controlling for income and education (Omachi et al., 2013). Additionally, patients with inadequate literacy and/or health literacy skills have difficulty comprehending medical forms, insurance information, and prescription labels (Williams, Baker, Honig, Lee, & Nowlan, 1998). The adverse outcomes, in part, may be the result of patients misunderstanding or rejecting health instructions due to their lack of literacy skills (Doak, Doak, & Root, 1996). To compound the primary problem of low health literacy skills, individuals who lack literacy skills feel shame and embarrassment, which has been shown to be an additional barrier in accessing health information because they are not willing to admit that they have a problem or are fearful in seeking help for their healthcare needs (Parikh, Parker, Nurss, Baker, & Williams, 1996). Patients who admitted to experiencing shame and having difficulty reading have often not told their spouses, children, and/or healthcare providers for fear of being negatively judged (Parikh et al., 1996). Research has also shown that self-reported education level may not accurately reflect the reading level of the patient (Davis et al., 1994; Mayeaux et al., 1995). In one study, participants had, on average, an 11th grade education, but were reading at the 7th to 8th grade reading level (Davis et al., 1994). Care must be taken not to assume reading level is the same as educational attainment because educational standards may differ from state to state and country to country. In addition to the impact of health literacy on one’s own health and healthcare utilization, there is evidence to suggest that parent health literacy is associated with child outcomes as well. For example, it has been shown that children with asthma who have parents with low literacy were more likely to visit the emergency room, be hospitalized, and miss school more frequently than children whose parents had higher levels of literacy (DeWalt, Dilling, Rosenthal, & Pignone, 2007), and parents with higher health literacy have healthier children and are more likely to breastfeed (Kaufman, Skipper, Small, Terry, & McGrew, 2001). Journal of Nursing Scholarship, 2014; 46:4, 218–228. C 2014 Sigma Theta Tau International Although there is a growing body of literature suggesting that health literacy is an important factor in the provision of healthcare services, healthcare professionals and organizations have been slow to adapt materials to ensure greater readability for all users. The average reading level for most Americans is at the 8th or 9th grade level, with one out of five adults reading at or below the 5th grade level. Additionally, two out of five adults 65 or older and inner-city minorities read at or below the 5th grade level (Doak et al., 1996). Previous studies have reported that as many as 53% to 90% of patient education materials are written at a 9th grade reading level or higher (Freda, 2005; Hoffmann & McKenna, 2006; Shieh & Hosei, 2008; Weintraub, Maliski, Fink, Choe, & Litwin, 2004). Other factors, in addition to reading level, contribute to the suitability of materials for those with limited education or literacy skills, including health literacy (Doak et al., 1996). Before interventions can be developed to improve health outcomes for both children and adults and before patients and families can be partners in their health care, commonly distributed patient education materials must be evaluated for appropriateness for low-education families. While there is a growing body of literature on health literacy and reading level of materials, there is much variability in the findings. Contributing to the variability is the way the materials are evaluated. Some researchers present a single readability score, and others have used both the Suitability of Materials (SAM) score and a readability score. The purpose of this study was to evaluate commonly used printed health materials for readability and suitability for patients with limited general or health literacy skills, while providing easy recommendations to healthcare providers for how to improve the materials. Both the SAM score (Doak et al., 1996) and a reading score that is a composite of seven commonly used tests for readability were used as more comprehensive ways to evaluate the materials. Having a more comprehensive evaluation of the materials will provide needed information to support specific revisions of the materials for improved comprehension by a wider range of patient ability levels and allows healthcare providers to develop materials that more specifically match the needs of their population. Methods Printed materials were evaluated from an academic health sciences center in the southern United States. The hospital is a tertiary center for the southwestern half of the state. As a referral center, three areas that are considered to be areas of excellence include cancer, 219 Suitability and Readability of Materials stroke, and maternal-infant care. The medical center serves a high percentage of minorities and underserved clients. Approximately 19% of patients are indigent, 29% receive Medicaid, over 40% are of a minority population, and 19% do not speak English. All printed materials for each of these units (total = 97) were included in the evaluation as follows: 28 items from the Stroke Center, 27 items from the Cancer Center, and 42 items from the Mother-Baby Unit. The sources of the materials varied from those obtained from national organizations such as the American Heart Association, the American Cancer Society, the U.S. Department of Health and Human Services, or the World Health Organization to institutiondeveloped materials or those that failed to identify the source of the information. Suitability of Materials Each material was evaluated for suitability using the SAM scale(Doak et al., 1996). The SAM scale was developed as a rigorous and quantifiable measure of attributes of printed materials that go beyond the assessment of reading level, but that influence readability (Doak et al., 1996). Although originally developed for use with printed materials, it has been successfully used with other media (Doak et al., 1996). The authors developed the tool and validated it with input from healthcare professionals from several cultures and from faculty and students from two prestigious universities (one school of public health and one school of medicine; Doak et al., 1996). The tool has become the most cited method for assessing patient education materials beyond reading level (Kang, Fields, Cornett, & Beck, 2005; Shieh & Hosei, 2008; Wallace, Rogers, Turner, Keenum, & Weiss, 2006; Wallace, Turner, Ballard, Keenum, & Weiss, 2005; Weintraub et al., 2004), and it is suggested for use by the Food and Drug Administration, the National Institutes of Health, and the National Library of Medicine. Suitability is based on ratings on 22 items that comprise six factors, which include content, literacy demand, graphics, layout and type, learning stimulation and motivation, and cultural appropriateness (Table 1). Each item is scored 0 (not suitable), 1 (adequate), or 2 (superior), and a raw score is calculated by adding the score for each item, when appropriate, and dividing by the total number of items scored out of a possible of 44. If an item is not applicable, no score is assigned and the denominator is adjusted as needed. The resulting percentages are classified as follows: not suitable (0–39%); adequate (40%–69%); or superior (70%–100%). A total of 97 materials were reviewed. A random sample of 35 materials was scored simultaneously and independently by two reviewers, and then scores were 220 Ryan et al. compared to establish interrater reliability. The reviewers were a post-baccalaureate research assistant and a second-year medical student. Any inconsistencies in scoring were discussed for clarification of the rules, and then the materials were reevaluated. Reviewers had 100% agreement on SAM overall classifications, with occasional differences on individual item scores that did not impact overall classifications. Interrater reliability for itemby-item analysis for the two raters was K = .78 (p < .001; 95% confidence interval [0.74–0.82]). Two reviewers evaluated the materials. The SAM tool was easy to use, and interrater reliability was acceptable. Readability Readability was evaluated using the Text Readability Consensus Calculator, a readability software tool (available free at http://www.readabilityformulas.com/freereadability-formula-tests.php). The program calculates the number of sentences, words, syllables, and characters in the text provided (Table 2). From those data, the readability assessment tool calculated readability using seven different commonly used (Charbonneau, 2012; Colaco, Svider, Agarwal, Eloy, & Jackson, 2013; Ellimoottil, Polcari, Kadlec, & Gupta, 2012; Lam, Roter, & Cohen, 2013; Langbecker & Janda, 2012; Stossel, Segar, Gliatto, Fallar, & Karani, 2012) formulas (Flesch Reading Ease formula, Flesch-Kincaid Grade Level, FOG Scale [Gunning FOG Formula], SMOG Index, Coleman-Liau Index, Automated Readability Index, and Linsear Write Formula), which resulted in seven readability scores and a composite grade level. Each of the seven readability measures is based on the English language and U.S. grade levels. Variability exists between the various measures as they use different criteria to compute the readability (e.g., some use sentence length while others use number of words or number of syllables). All seven measures have been widely used in the literature. The consensus calculator provides each of the seven outputs as well as a composite score across all seven methods. The sample text for smaller materials was 200 words, and for larger materials a sample of 500 words was used in the calculation. A random selection of materials was also retested using a different sample of text for reliability. The readability formula tool analyzed the text for the number of sentences, average sentence length and number of words, average number of syllables, and average number of characters per word in the sample for a composite grade level. The composite grade levels were then classified as superior (5th grade), adequate (6th, 7th, and 8th grade), or not suitable (9th grade and above; Doak et al., 1996). The readability scores were also used in the calculation of the Journal of Nursing Scholarship, 2014; 46:4, 218–228. C 2014 Sigma Theta Tau International Suitability and Readability of Materials Ryan et al. Table 1. Summary of Frequency of Suitability Assessment of Materials (SAM) Scores by Item for All Patient Material (N = 97) SAM evaluation factors Content Purpose is evident Content about behaviors Scope is limited Summary or review included Literacy demand Reading grade level Writing style, active voice Vocabulary Context is given first Advance organizers Graphics Cover graphic shows purpose Type of graphic Relevance of illustrations Lists and tables explained Captions used for graphics Layout and typography Layout factors Typography Subheadings (‘chunking’) used Learning, stimulation, and motivation Interaction used Behaviors are modeled and specific Motivation/self-efficacy Cultural appropriateness Match in logic, language, experience Cultural images and examples Not suitable Score of 0 n (%) Adequate Score of 1 n (%) Superior Score of 2 n (%) 8 (8.2%) 22 (22.7%) 15 (15.5%) 90 (92.8%) 19 (19.6%) 43 (43.3%) 39 (40.2%) 5 (5.2%) 70 (72.2%) 32 (33.0%) 43 (44.3%) 2 (2.1%) 27 (27.8%) 11 (11.3%) 23 (23.7%) 4 (4.1%) 2 (2.1%) 48 (49.5%) 39 (40.2%) 49 (50.5%) 28 (28.9%) 20 (20.6%) 22 (22.7%) 47 (48.5%) 25 (25.8%) 65 (67.0%) 75 (77.3%) 16 (16.5%) 5 (5.2%) 26 (26.8%) 4 (4.1%) 51 (52.6%) 51 (52.6%) 52 (53.6%) 53 (54.6%) 52 (53.6%) 17 (17.5%) 10 (10.3%) 22 (22.7%) 18 (18.6%) 41 (42.3%) 11 (11.3%) 2 (2.1%) 2 (2.1%) 7 (7.2%) 31 (32.0%) 26 (26.8%) 39 (40.2%) 64 (66.0%) 69 (71.1%) 51 (52.6%) 56 (57.7%) 14 (14.4%) 5 (5.2%) 35 (31.6%) 44 (45.4%) 48 (49.5%) 6 (6.2%) 39 (40.2%) 44 (45.4%) 1 (1.0%) 2 (2.1%) 55 (56.7%) 64 (66.0%) 41 (42.3%) 31 (32.0%) Note. Twenty materials did not include cover graphic and 18 did not contain graphics; percentages adjusted for nonapplicable factors. SAM score since readability constitutes one criterion of suitability (Doak et al., 1996). Results Overall Suitability of Materials Table 1 summarizes the findings for the SAM evaluation by item across all three types of materials (stroke, cancer, and maternal-infant). Overall, of the 97 materials evaluated using the SAM instrument, 11.3% were not suitable, 57.7% were adequate, and 30.9% were superior. The readability composite score rating indicated that 27.8% were not suitable, 50.5% were adequate, and 21.6% were superior (Tables 3, 4, and 5). Of the 97 patient materials evaluated, 93% of the materials were rated as not suitable with respect to including a summary or review, which can help patients retain the information and understand the content given in the materials. Fifty-eight percent of the materials were rated as not suitable with respect to including patient interaction, which can help to stimulate and motivate patients in changing their health-related behaviors or to comply with healthcare recommendations. Journal of Nursing Scholarship, 2014; 46:4, 218–228. C 2014 Sigma Theta Tau International Overall Readability Twenty-three percent (22 of 97) of the materials were written at the 5th grade reading level or below (superior). Forty-eight percent (47 of 97) were written for 6th to 8th grade level (adequate), and 29% (28 of 97) were written at or above the 9th grade level (not suitable). Suitability and Readability by Topic Area (Stroke, Cancer, Maternal-Child) Stroke. Suitability assessment for the Stroke Center materials were as follows: 10.7% were rated as not suitable, 71.4% were rated as adequate, and 17.9% were rated as superior. Readability assessments for the Stroke Center materials were as follows: 32.1% were rated as not suitable, 60.7% were rated as adequate, and 7.1% were rated as superior (see Table 3). Cancer. Suitability assessment for the Cancer Center materials were as follows: 25.9% rated as not suitable, 14.8% rated as adequate, and 59.3% rated as superior. Readability assessment for the Cancer Center materials 221 Suitability and Readability of Materials Ryan et al. Table 2. Text Readability Consensus Calculator Readability test Criteria Flesch Reading Ease score Average sentence length Average no. of syllables per word Gunning FOG Formula Average sentence length Percentage of “hard words” (3+ syllables) Flesch-Kincaid grade level Average sentence length Average no. of syllables per word Average no. of characters per word No. of words No. of sentences No. of polysyllable words Average number of letters per word Average no. of words per sentence No. of sentences No. of polysyllable words No. of 1- to 2-syllable words Based on measures above Coleman-Liau Index SMOG Index Automated Readability Index Linsear Write Formula Readability consensus Output example Score form 0—100 90–100 = 5th grade reading level 60–70 = 8th –9th grade reading level 0–30 = college graduate reading level 5 = readable 10 = hard 20 = very difficult Average student of the grade can read the text. Outputs a U.S. school grade level 12.2 = 12th grade Average student of the grade can read the text. Outputs a U.S. school grade level 10.6 = 10th or 11th grade Average student of the grade can read the text. Outputs a U.S. school grade level 7.4 = 7th grade Average student of the grade can read the text. Outputs a U.S. school grade level 3 = 3rd grade Average student of the grade can read the text. Outputs a U.S. school grade level 14.6 = college Grade level: 11 = 11th grade Reading level: 11 = average Age level: 15–17 years Note. FOG = Gunning’s Fog Index or FOG; SMOG = McLaughlin’s SMOG Readability Formula. were as follows: 25.9% rated as not suitable, 14.8% rated as adequate, and 59.3% rated as superior (see Table 4). Maternal-child. Suitability assessment for the Mother-Baby Unit materials were as follows: 2.4% were rated as not suitable, 76.2% were rated as adequate, and 21.4% were rated as superior. Readability assessment for the Mother-Baby Unit materials were as follows: 26.2% were rated as not suitable, 64.3% were rated as adequate, and 9.5% were rated as superior (see Table 5). Discussion Even though a significant number of adults in the United States have inadequate general and health literacy skills (Abrams, Klass, & Dreyer, 2009; Kirsch et al., 2002; Kutner et al., 2006), healthcare systems continue to develop and use educational materials that are not appropriate for many of the patients and families that they serve. While this has been widely reported in the literature, changes have not been implemented to reflect the current state of the science and recommendations from agencies such as the National Institutes of Health and the Agency for Healthcare Research and Quality (AHRQ). Current models of care such as the patient- and 222 family-centered medical home model suggest that the provider and the patient or family are integral partners and that the family is actively involved in the decisionmaking process (Yin et al., 2012). However, that concept assumes that patients or their representatives are equally equipped to access, process, and understand complex health information, which is not the case. It is important for healthcare providers and educators to take responsibility for ensuring that important information is presented in a clear and consistent manner so that it is accessible to most patients. In one recent study about the provision of health information related to anticipatory guidance on 19 different common topics by pediatricians, 12% to 40% of parents, the majority of which had a high school equivalent education, said that they either did not receive wanted information on the topics or that they did not understand the information provided compared to 0 to 26% of the parents with higher levels of education (Davis, Jones, Logsdon, Ryan, & Wilkerson-McMahon, 2013). The current study examined 97 materials from three areas of an urban academic health sciences center that serves as the tertiary referral center. The areas from which these materials were retrieved represent areas of excellence for patients throughout the city, region, and state needing those services. Yet, we found that only 7% of the stroke materials, 59% of the cancer materials, and Journal of Nursing Scholarship, 2014; 46:4, 218–228. C 2014 Sigma Theta Tau International Suitability and Readability of Materials Ryan et al. Table 3. Evaluation of Suitability and Readability of Stroke Patient Materials Education material title How Can I Quit Smoking Heart Healthy Eating Let’s Talk About High Blood Pressure and Stroke Let’s Talk About Living at Home After Stroke Let’s Talk About Lifestyle Changes to Prevent Stroke You Can Quit Smoking Let’s Talk About Driving After Stroke Let’s Talk About the Stroke Family Caregiver Let’s Talk About Ischemic Strokes and Their Causes Let’s Talk About Carotid Endarterectomy What Are High Blood Cholesterol and Triglycerides? Let’s Talk About Stroke, TIA and Warning Signs Let’s Talk About Feeling Tired After Stroke Let’s Talk About a Stroke Diagnosis Let’s Talk About Complications After Stroke Let’s Talk About Risk Factors for Stroke Let’s Talk About Changes Caused by Stroke Let’s Talk About Stroke and Rehabilitation What Do My Cholesterol Levels Mean? Let’s Talk About Children and Stroke Keys for Quitting Let’s Talk About Anticoagulants and Antiplatelet Agents Patient’s Clinical Path Understanding Atrial Fibrillation With Stroke Time Saved is Brain Saved Tissue Plasminogen Activator Explaining Stroke Pamphlet Stroke Smart Magazine SAM score SAM classification Grade level Grade classification 80 75 73 71 70 68 68 66 61 59 57 57 57 57 57 55 55 52 50 50 48 48 45 43 41 39 39 36 superior superior superior superior superior adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate not suitable not suitable not suitable 5 7 7 8 7 6 7 8 8 7 7 7 8 9 10 7 10 11 8 8 5 9 9 8 9 8 10 9 superior adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate not suitable not suitable adequate not suitable not suitable adequate adequate superior not suitable not suitable adequate not suitable adequate not suitable not suitable Note. Evaluation was based on the SAM instrument and readability consensus calculator (n = 28). SAM = Suitability Assessment of Materials; TIA = transient ischemic attack. 10% of the maternal-child materials were rated at or below a 5th grade reading level, which is considered the most appropriate level. Of all of the materials (N = 97) evaluated, 28% were deemed as not suitable or at a 9th grade reading level or higher. Importantly, many materials from the American Cancer Society were written at a lower reading level, which explains the higher percentage of cancer materials that were found to be written at the 5th grade reading level as compared to the other specialty areas. However, there was variability among the materials from the same organization and across organizations. When considering both the SAM scale and readability together, 2% of the maternal-child, 4% of the stroke, and 56% of the cancer materials were rated as superior on both scores. This is not acceptable and may be one factor that contributes to health disparities for poor and underserved families. While many social determinants of health are complex and difficult to resolve, improving health education and health communication is more easily modified and may improve patients’ partnership with healthcare providers to create care plans, shared decision mak- Journal of Nursing Scholarship, 2014; 46:4, 218–228. C 2014 Sigma Theta Tau International ing, and satisfaction with care. These factors, and others, may lead to improved outcomes. The SAM instrument identifies additional criteria upon which to evaluate materials (content, literacy demand, graphics, layout and typography, learning stimulation and motivation, and cultural appropriateness). The instrument can easily be used by healthcare providers to improve written materials. For example, the purpose of the handout should be clear. Ask yourself, will the patient know why he/she should read and understand this material? Is it focused on one topic? Literacy demand includes more than word and sentence length and complexity. Consideration should be given to using active voice and in the organization of the information. Are there subheadings? Do the subheadings clearly guide the patient by organizing thoughts, ideas, and tasks in the appropriate order? Additionally, key points should be summarized at the end to reinforce the information. Overall, 93% of the materials in our study were not suitable with respect to including a summary or 223 Suitability and Readability of Materials Ryan et al. Table 4. Evaluation of Suitability and Readability of Cancer Patient Materials Education material title Managing Chemotherapy Side Effects Hair loss Anemia Appetite changes Memory changes Mouth and throat changes Nausea and vomiting Constipation Bleeding problems Pain Fatigue Nerve changes Swelling Urination changes Diarrhea Sexual and fertility changes in men Sexual and fertility changes in women Eating Hints Chemotherapy and You Pain Control Fondaparinux Injection Fact Sheet Carboplatin and Etoposide Fact Sheet Bevacizumab Injection Fact Sheet Pegfilgrastim Injection Fact Sheet Zofan Fact Sheet Resource Center Carboplatin and Gemcitabine Fact Sheet Erlotinib Tablet Fact Sheet SAM score SAM classification Grade level Grade classification 82 82 82 82 82 82 80 80 80 77 77 77 77 75 75 75 66 64 61 42 39 39 34 31 30 29 26 superior superior superior superior superior superior superior superior superior superior superior superior superior superior superior superior adequate adequate adequate adequate not suitable not suitable not suitable not suitable not suitable not suitable not suitable 3 4 4 4 4 4 3 4 4 3 3 4 4 4 4 5 7 8 7 8 9 10 11 10 10 9 9 superior superior superior superior superior superior superior superior superior superior superior superior superior superior superior superior adequate adequate adequate adequate not suitable not suitable not suitable not suitable not suitable not suitable not suitable Note. Evaluation was based on the SAM instrument and readability consensus calculator (n = 27). SAM = Suitability Assessment of Materials. review. Summarizing is important as it points out the most critical information and the repetition reinforces learning. Graphics should be used to enhance the text, but not to make it more complicated. Ask yourself if the graphic adds to the material or distracts the reader from the content. Is the information “nice to know” or critical to one’s understanding of the material? Does the graphic “show” the patient what to do? As healthcare professionals, we may be desensitized to the complexity of some graphics that may be used in health information because these types of diagrams are frequently used in the scientific literature. However, patients, especially those with limited education, may find that the diagrams add to their confusion rather than helping them to understand it. For example, one of the materials we reviewed showed a picture of a brain with much more detail than what the patient needed. If a patient wants more in-depth information, we can refer them to additional resources; but we should consider plain language and simple graphics as a general rule. It has also been shown that even those with higher levels of education and reading abilities prefer materials that are written in more simple language with ap- 224 propriate graphics over more complex and densely written materials (Davis et al., 1996). Plain language materials may be welcome by all patients. Another key element for written materials is stimulation and motivation (Davis et al., 1996; Doak et al., 1996). Do we tell the patient why it is important for them to know the material? Do we tell them exactly what we want them to do? Do we give them information that will motivate them to take action? For example, “Cleaning your wound two times every day will prevent infection.” Lastly, but importantly, are the materials culturally relevant? This requires a good grasp of the demographics of the population you serve and knowledge of the similarities and differences in the health and dietary practices, values, and beliefs of different individuals and groups. In addition to making the materials culturally appropriate, one-on-one conversations should include such questions as, “Do you see things on this diet that you might eat in your home?” It is important to individualize the materials to meet the needs of a diverse population. Reading level is critically important, but there are other factors to consider in designing or selecting appropriate Journal of Nursing Scholarship, 2014; 46:4, 218–228. C 2014 Sigma Theta Tau International Suitability and Readability of Materials Ryan et al. Table 5. Evaluation of Suitability and Readability of Maternal Patient Materials Education material title Safe Sleep for Your Baby Hearing RSV is the No.1 Cause of Hospitalization in Babies Under One Year of Age Holding Your Baby Skin-to-Skin Preparing Formula in Care Settings Hold Them Hug Them Love Them But Never Shake a Baby Breastfeeding for African American Women Infant Feeding Cues Crying/Colic: Hints for Soothing Your Baby Quiet Time Is Family Bonding Time Breastfeeding the Preterm Baby The Edinburgh Postpartum Depression Scale Fetal Movement Monitoring Kick Count A New Beginning: Your Personal Guide to Postpartum Care Visitation Information Perineal Care Car Safety for Your Baby Exercise Sheet Unmarried Parents Make the Best Choice for Your Child Welcome to the WHAS Crusade NICU Bathing Your Baby Breastmilk is Best Pumping Log What Parents of Near-Term Infants Need to Know Postpartum Exercise: Tips for Cesarean Recovery Providing Breastmilk to Your Baby Breastfeeding Information Bosnian The Little While: For Parents Experiencing the Death of a Very Small Infant Colostrum Breastmilk Feedings in the NICU Welcoming Our New Arrival: The Lactation Center Prevent Shaken Baby Syndrome Jaundice and the Newborn Infant Shots for Tots Kentucky Early Hearing Detection & Intervention Program Kentucky Newborn Screening Program To the Parents of Our NICU Infants: About Pain Attention Unmarried Parents Postpartum Discharge Instructions Miscarriage Ectopic Pregnancy 2012 Classes for Expectant and New Parents Hepatitis B Vaccine Which Birth Control Method Is Right for Me SAM score SAM classification Grade level Grade classification 84 77 77 73 73 73 73 71 70 68 68 68 68 68 66 66 66 64 64 63 63 61 61 61 61 59 59 59 57 55 55 55 50 50 47 47 45 43 43 42 42 34 superior superior superior superior superior superior superior superior superior adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate not suitable 7 5 6 6 6 6 8 6 8 5 5 7 8 10 7 7 8 6 9 8 8 7 10 11 12 6 8 10 7 5 8 8 6 9 7 11 10 6 10 7 9 10 adequate superior adequate adequate adequate adequate adequate adequate adequate superior superior adequate adequate not suitable adequate adequate adequate adequate not suitable adequate adequate adequate not suitable not suitable not suitable adequate adequate not suitable adequate superior adequate adequate adequate not suitable adequate adequate not suitable adequate not suitable adequate not suitable not suitable Note. Evaluation was based on the SAM instrument and readability consensus calculator (n = 42). SAM = Suitability Assessment of Materials; RSV = Respiratory syncytial virus; WHAS-TV; NICU = neonatal intensive care unit. materials. Even for patients with higher levels of education, there are still concerns regarding the presentation of information. A number of other factors may contribute to their absorption and subsequent ability to use the information for improved health outcomes and informed decision making. For example, concerns regarding a new health diagnosis, ability to pay for needed treatment, transportation for needed services, and dependent care during illness could all impact the ability to conJournal of Nursing Scholarship, 2014; 46:4, 218–228. C 2014 Sigma Theta Tau International centrate on the health information. Distraction on top of limited literacy skills compounds the problem of reading, understanding, and using health information that is too complex or written at a level that is difficult to understand. Lastly, other factors beyond reading influence one’s ability to understand and use health information. Like most studies, there are limitations to the current study. Only three units in the hospital were included and materials were from only one hospital, which is an 225 Suitability and Readability of Materials academic medical center in the southern United States. However, many of the materials came from national professional organizations, which are likely used by other hospitals across the country. Other materials were developed locally and may, or may not, be relevant to other organization. Ryan et al. identify the optimal delivery method for various populations. Hopefully, these steps will lead to a system of patient education that respects the skills and needs of individuals and families. All health care professional have a responsibility to evaluate the materials being used with our patients and to provide them with information that can be easily used to be active participants in their health and well-being. Implications As we have demonstrated, the SAM tool is a simple method that can be used by healthcare providers across the globe to improve written health education materials. Improving outcomes and reducing health disparities is increasingly important, especially for those families with limited literacy skills and resources. One step to increasing compliance to written instructions is improving the quality of the materials by decreasing the reading level and increasing the suitability for all patients and their families. Regardless of whether a patient has higher or lower literacy skills, patients prefer health information that is communicated in clear, concise, and plain language and incorporates simple design features (Davis et al., 1996; Stableford & Mettger, 2007). Additional steps are needed to ensure that healthcare providers and organizations adopt an overarching policy to be a “health literate organization” (Brach et al., 2012). A health literate organization includes, in part, leadership that sets the standard and provides appropriate resources to support health literacy initiatives; ongoing evaluation of organizational policies and practices, patient and staff needs, and the impact of change on health outcomes; and involvement of diverse audiences in the development and testing of educational messages and delivery methods (Brach et al., 2012). Patient- and family-centered care and medical home models cannot be achieved without attention being paid to health literacy. In the academic center where the study was conducted, steps have been taken to improve health information, based on our findings. For example, a multi-disciplinary Patient Education Oversight Committee has been established, which meets regularly. Several units have adopted improved patient education as an evidence-based project, and an initial “Nurse as Teacher” conference was hosted this year. These initiatives have led to an increased focus on patient preparation for discharge as well as collaboration with community organizations to improve health information. Feedback from patients and families has been collected to allow revisions and redirections. Preliminary steps have begun to develop and test new methods of delivering health information using currently available electronic media as a substitute or supplement to written materials. 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Academic Pediatrics, 12(2), 117– 124. Journal of Nursing Scholarship, 2014; 46:4, 218–228. C 2014 Sigma Theta Tau International Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.