Neurology patient education materials: do our educational aids fit our patients' needs?

The purpose of this study was to assess the suitability of various neurology patient education brochures, as well as neurology information on the World Wide Web, to determine whether they were appropriate for patients with low literacy. A convenience sample of 520 patients in university-based public and private neurology clinics participated. In this cross-sectional study, the patients' reading levels were assessed by using the Rapid Estimate of Adult Literacy in Medicine. Forty-three patient education materials were assessed for reading level by using the Fog Index and for suitability characteristics (including content, type and relevance of graphics, layout, type size and fonts, and motivating qualities) by using the Suitability Assessment of Materials. The mean education level of patients was 12th grade; however, the mean reading level was 7th-8th grade. Of the assessed materials, 91% were written at a 9th-grade level or above, even though only 58% of patients read at a 9th-grade level. Only 14% of the materials were considered to have superior suitability, whereas 58% were adequate, and 28% were determined not suitable. Thus, the available neurology patient education aids are not matched to the patient population or to the average U.S. reading levels. Ideally, information needs to be written at a 9th-grade level or below. Instructional graphics, simpler words, patient interaction, and cultural sensitivity improve material suitability.

Comparing the effectiveness of video and written material for improving knowledge among sleep disorders clinic patients with limited literacy skills.

BACKGROUND: Health care professionals often use written material or video recordings to teach their patients without knowing which is more effective for comprehension of the information. METHODS: Patients watched either an instructional videotape about sleep apnea or read a newly designed brochure, then responded to a structured questionnaire containing 11 knowledge-based questions and 1 open-ended question (requesting suggestions for improvement of the brochure or videotape). RESULTS: Mean reported educational level was grade 12, and mean reading level was between grade 7 and 8. Using video significantly improved only two areas of knowledge for low-level (below grade 8) readers: defining sleep apnea (66% vs 43%) and identifying what continuous positive airway pressure (CPAP) does for the patient (94% vs 78%). Patients requested material with more diverse cultural representation, more information on treatment and outcomes, and fewer polysyllabic words. CONCLUSIONS: Emphasis on diagnosis and treatment, explained using simple words, should be reflected in the content of patient education brochures or videos. Providing information by video alone may have limited benefits.

Muscular strength, body composition and health responses to the use of testosterone enanthate: a double blind study.

To determine the effect the steroid, testosterone enanthate (TE) had on upper body strength, body composition and health. Twenty one male weight training subjects were randomly assigned in a double blind method to either a 3.5 mg(-1) x kg(-1) TE (n=11) or placebo (n=10) weight training group. The subjects were monitored during a 12 week administration phase and a subsequent 12 week follow up phase. Subjects were tested on a number of strength and size measurements, whilst having their health monitored. The results from the study revealed that the testosterone/weight training group improved significantly (p<0.05) more than the placebo/weight training group during and immediately after the administration phase on a 1 repetition maximum bench press. With regards to body composition, body weight, arm girth and rectus femoris circumference all increased significantly greater in the TE group compared to the placebo. Furthermore, the abdomen skinfold showed significant decreases in the TE group compared to the placebo group at post testing, follow up mid testing and the follow up post testing occasions. With the exception of the abdomen skinfold no within or between group differences were evident following a cycling off period of 12 weeks. Changes to baseline health indicators were reported in some subjects following testosterone usage. This included an average elevation in systolic blood pressure in all TE subjects by 10 mm Hg, a mild increase in hereditary frontal alopecia, increased muscle tightness (hamstrings and pectorals), a mild increase in libido over the first two weeks with a subsequent fall to normal, mild acne, subjective changes to personality including an increase in aggression, irritability and positive mood responses. Consequently, moderate doses of TE combined with weight training can result in short term significant changes in upper body strength and body composition, with corresponding changes to baseline health in some individuals.

Presentation and reading level of sleep brochures: are they appropriate for sleep disorders patients?

OBJECTIVE: Sleep-disorders patients must be given information and health education they understand. The purpose of this study was twofold: (1) to assess suitability of American Sleep Disorders Association and National Sleep Foundation patient education brochures; and (2) to assess one widely used brochure, using patient input and patient literacy level, as a model for development of future materials. DESIGN: Twelve American Sleep Disorders Association and National Sleep Foundation brochures were assessed for reading level using Grammatik, and for design, presentation, and motivating qualities using the Suitability Assessment of Materials (SAM). Patient literacy level was assessed using the Rapid Estimate Of Adult Literacy in Medicine (REALM). SETTING: The Louisiana State University Medical Center sleep clinic, faculty private sleep clinic, and in the sleep center laboratory. PATIENTS OR PARTICIPANTS: During the months of February-May 1997, 170 sleep disorders patients, 39% African American, 59% white participated in the study. Participants ranged in age from 18-73 years, with a mean age of 46. MEASUREMENTS AND RESULTS: Suitability scores for the 12 brochures indicate that none scored in the superior range, 83% scored adequate, and 17% scored not suitable. Ninety-four percent of the brochures were written on a 12th grade level or higher, yet 37% of the sleep patients tested were reading at less than a 9th grade level. Low-level readers were significantly more likely than their higher-reading-level counterparts to report that a brochure was too long (22% vs 12%; p < .05), and that they would need help reading it (44% vs 3%; p < .001). CONCLUSIONS: Patients need sleep information given to them on a level they understand. When developing and selecting appropriate materials, reading level, length, and suitability of written material should be considered.

Intervention to increase mammography utilization in a public hospital.

OBJECTIVE: To study the effects of three approaches to increasing utilization of screening mammography in a public hospital setting in Northwest Louisiana. DESIGN: Randomized intervention study. POPULATION: Four hundred forty-five women aged 40 years and over, predominantly low-income and with low literacy skills, who had not had a mammogram in the preceding year. INTERVENTION: All interventions were chosen to motivate women to get a mammogram. Group 1 received a personal recommendation from one of the investigators. Group 2 received the recommendation plus an easy-to-read National Cancer Institute (NCI) brochure. Group 3 received the recommendation, the brochure, and a 12-minute interactive educational and motivational program, including a soap-opera-style video, developed in collaboration with women from the target population. MEASUREMENTS AND MAIN RESULTS: Mammography utilization was determined at 6 months and 2 years after intervention. A significant increase (p = .05) in mammography utilization was observed after the intervention designed in collaboration with patients (29%) as compared with recommendation alone (21%) or recommendation with brochure (18%) at 6 months. However, at 2 years the difference favoring the custom-made intervention was no longer significant. CONCLUSIONS: At 6 months there was at least a 30% increase in the mammography utilization rate in the group receiving the intervention designed in collaboration with patients as compared with those receiving the recommendation alone or recommendation with brochure. Giving patients an easy-to-read NCI brochure and a personal recommendation was no more effective than giving them a recommendation alone, suggesting that simply providing women in a public hospital with a low-literacy-level, culturally appropriate brochure is not sufficient to increase screening mammography rates. In a multivariate analysis, the only significant predictor of mammography use at 6 months was the custom-made intervention.

A polio immunization pamphlet with increased appeal and simplified language does not improve comprehension to an acceptable level.

We used a randomized trial to compare two polio vaccine pamphlets written on a sixth grade level--the vaccine information statement prepared by the Centers for Disease Control (CDC) and an easy-to-read pamphlet we developed (LSU)--for reading ability, comprehension and preference among 610 parents with a broad range of demographic characteristics. Parents at all reading levels and incomes preferred LSU (76% vs. 21%, P < 0.001). Although readers of LSU achieved significantly higher comprehension (65% vs. 60%, P < 0.05) this difference may not be clinically significant. The information items presented with instructional graphics were the only items on which differences in comprehension levels achieved both clinical and statistical significance. Comprehension was lowest for the CDC mandated information on risks and the National Injury Compensation. Our findings demonstrate that simplifying written immunization material and making it more suitable will increase appeal, but such modification may not raise comprehension to an acceptable level without use of instructional graphics. Health education materials intended for general parent populations, which are written on a sixth grade reading level, may not adequately educate parents or prepare them for a discussion with their physicians.

Literacy in patients with a chronic disease: systemic lupus erythematosus and the reading level of patient education materials.

OBJECTIVE: (1) To assess literacy in a sample of patients with systemic lupus erythematosus (SLE); (2) to evaluate the reading level of patient education materials specific to SLE; and (3) to compare patient literacy levels to the readability of materials written for patients with SLE. METHODS: Rapid Estimate of Adult Literacy in Medicine, a reading recognition test, was given to 94 patients with SLE. Socioeconomic status was assessed using Nam-Powers. Patient education materials frequently used with these patients were assessed for readability grade level. RESULTS: The patients with SLE were reading on an average 7th-8th grade level; their average educational level (last grade completed in school) was 11.9. The average socioeconomic status (SES) according to the Nam-Powers assessment was 43, indicating high school completed, no college, an income range of $5000-$10,000, and occupations such as household workers and laborers. Multiple linear regression revealed that race and education correlated with reading (p < 0.001), but age, sex, and SES did not. The readability of surveyed SLE patient education materials ranged from 7th-15th grade level. Eighty-nine percent were written at a 9th grade level or above and were therefore inappropriate for about half the patients surveyed. CONCLUSION: Reading skills below high school level existed for 48% of patients surveyed, yet only 11% of SLE patient education materials were written below a 9th grade level. Current SLE patient education materials are written on too high a level for many patients. Identifying patients with low literacy may help provide more appropriate patient education and better medical care.

Parent comprehension of polio vaccine information pamphlets.

BACKGROUND: Medical information pamphlets often are written using language that requires a reading level higher than parents of many pediatric patients have achieved. Anecdotal reports suggest that many parents may not readily understand the federally mandated Public Health Service vaccine information pamphlets prepared by the Centers for Disease Control and Prevention (CDC) in 1991. The level at which the pamphlets need to be written for low-reading-level parents is undetermined, as is whether parents reading at higher levels will accept low-reading-level materials. METHODS: To determine whether a simple pamphlet prepared at a low reading level using qualitative and adult education techniques would be preferable to the available CDC polio vaccine information pamphlet, we conducted an integrated qualitative-quantitative study. We compared the parent reading time and comprehension of a simplified pamphlet (Louisiana State University, LSU) comprising 4 pages, 322 words, 7 instructional graphics, and a text requiring a 6th grade reading ability with the equivalent 1991 CDC vaccine information pamphlet comprising 16 pages, 18,177 words, no graphics, and a text requiring a 10th grade reading level. We measured the reading ability of 522 parents of pediatric patients from northwest Louisiana seen at public clinics (81%) and in a private office (19%). Of the entire group, 39% were white, 60% African-American, and 1% Hispanic; the mean age was 29 years; the mean highest grade completed was 12th grade 3 months; and the reading level was less than 9th grade in 47% of parents and less than 7th grade in 20%. After parents were given one of the pamphlets to read, their reading time, comprehension, and attitude toward the pamphlet were measured. RESULTS: Mean comprehension was 15% lower for CDC than for LSU (56% vs 72% correct; P < .001) and reading time was three times longer for CDC than for LSU (13 minutes 47 seconds vs 4 minutes 20 seconds; P < .0001). These trends were significant for parents reading at all but the lowest levels. Mean comprehension and reading time did not differ among parents reading at the third grade level or less. However, mean comprehension was greater and reading time lower for LSU among parents at all reading abilities greater than the third grade. Parents in the private practice setting took the longest time to read the CDC (20 minutes 59 seconds vs 5 minutes 46 seconds, LSU), yet their comprehension on the LSU was significantly higher than on the CDC (94% vs 71%; P < .0001). Two focus groups of high-income parents were unanimous in preferring the LSU. CONCLUSIONS: A short, simply written pamphlet with instructional graphics was preferred by high- and low-income parents seen in private and public clinics. The sixth grade reading level appears to be too high for many parents in public clinics; new materials aimed at third to fourth grade levels may be required. The new 1994 CDC immunization materials, written at the eighth grade level, may still be inappropriately high. The American medical community should adopt available techniques for the development of more effective patient-parent education materials.

Improving patient education for patients with low literacy skills.

Patients who misunderstand their diagnosis and treatment plans usually exhibit poor compliance. The 90 million adult Americans with low literacy skills struggle to understand such essential health information as discharge instructions, consent forms, oral instructions and drug labels. The Joint Commission on Accreditation of Health Organizations (JCAHO) now requires that instructions be given on a level understandable to the patient. Most physicians tend to give too much information on too high a level for many patients to understand. Physicians who speak in simpler language, repeat their instructions and demonstrate key points, while avoiding too many directives, enhance their patients' understanding. Combining easy-to-read written patient education materials with oral instructions has been shown to greatly enhance patient understanding. To be effective with patients whose literacy skills are low, patient education materials should be short and simple, contain culturally sensitive graphics and encourage desired behavior. Compliance with therapy also may be improved by including family members in the patient education process.

Reading ability of parents compared with reading level of pediatric patient education materials.

OBJECTIVES: To test the reading ability of parents of pediatric outpatients and to compare their reading ability with the ability necessary to read commonly used educational materials; to compare individual reading grade levels with the levels of the last grade completed in school; and to further validate a new literacy screening test designed specifically for medical settings. DESIGN: Prospective survey. SETTING: Pediatrics outpatient clinic in a large, public university, teaching hospital. PARTICIPANTS: Three hundred ninety-six parents or other caretakers accompanying pediatric outpatients. MEASUREMENTS: Demographics and educational status were assessed using a structured interview. Reading ability was tested using the Rapid Estimate of Adult Literacy in Medicine (REALM) and the Wide Range Achievement Test-Revised. Written educational materials were assessed for readability levels with a computer program (Grammatik IV). RESULTS: The mean score on the REALM for all parents placed them in the seventh to eighth grade reading range, despite the mean self-reported last grade completed in school being 11th grade 5th month. Wide Range Achievement Test-Revised scores correlated well with REALM scores (0.82). Eighty percent of 129 written materials from the American Academy of Pediatrics, the Centers for Disease Control, the March of Dimes, pharmaceutical companies, and commercially available baby books required at least a 10th grade reading level. Only 25% of 60 American Academy of Pediatrics items and 19% of all materials tested were written at less than a ninth grade level, and only 2% of all materials were written at less than a seventh grade level. CONCLUSION: This study demonstrates that parents' self-reported education level will not accurately indicate their reading ability. Testing is needed to screen at-risk parents for low reading levels. In a public health setting, a significant amount of available parent education materials and instructions require a higher reading level than most parents have achieved. In such settings, all materials probably should be written at less than a high school level if most parents are to be expected to read them. The REALM can easily be used in busy public health clinics to screen parents for reading ability.

Rapid estimate of adult literacy in medicine: a shortened screening instrument.

BACKGROUND: This study was conducted to validate a shortened version of the Rapid Estimate of Adult Literacy in Medicine (REALM). This screening instrument is designed to be used in public health and primary care settings to identify patients with low reading levels. It provides reading grade estimates for patients who read below a ninth-grade level. The REALM can be administered in one to two minutes by personnel with minimal training. METHODS: Two hundred and three patients in four university hospital clinics (internal medicine, family practice, ambulatory care, and obstetrics/gynecology) were given the REALM and three other standardized reading tests: the reading recognition section of the Peabody Individual Achievement Test-Revised (PIAT-R), the Wide Range Achievement Test-Revised (WRAT-R), and the Slosson Oral Reading Test-Revised (SORT-R). One hundred inmates at a state prison were also given the REALM twice, one week apart, to determine test-retest reliability. RESULTS: The REALM correlated well with the three other tests. (Correlation coefficients were 0.97 [PIAT-R], 0.96 [SORT-R], and 0.88 [WRAT-R].) All correlations were significant at P < .0001. Test-retest reliability was 0.99 (P < .001). CONCLUSIONS: The REALM provides an estimate of patient reading ability, displays excellent concurrent validity with standardized reading tests, and is a practical instrument for busy primary care settings.

Reading ability in patients in substance misuse treatment centers.

Adult inpatients in state-supported (public) and private substance misuse treatment settings were tested for reading ability. Patient education materials and consent forms were assessed for readability levels. Public patients' mean reading levels were significantly lower than those of private patients, and were 4 to 5 years below the level needed to read and understand standard treatment materials. More than half of the public and almost one-third of the private patients tested were reading below a 9th grade level. Standard treatment materials were written on 11th to 12th grade reading levels; admission and consent forms were written on 12th to 18th grade levels. Patients in substance misuse settings should be tested for literacy levels upon admission and provided with materials commensurate with their reading ability.

Recurrent adenoid cystic carcinoma of the trachea: intraluminal radiotherapy.

Malignant neoplasms of the trachea are rare lesions, of which adenoid cystic carcinoma constitutes 30%. A case of extensive tumor recurrent after primary radiotherapy is presented. Surgical resection and radioisotope implantation were impossible. A method was devised for placement of intraluminal iridium 192 by casting six small hollow plastic tubes to the outer circumference of a Silastic endotracheal tube. This was an easy, safe, and effective method of delivering radiation to the trachea while sparing other vital structures and organs. Excellent tumor response and palliation were achieved. The literature is reviewed and the problems in diagnosis of this tumor are discussed. A comprehensive plan for early diagnosis is presented. All current methods of treatment are discussed, and the need for aggressive surgical management is stressed.