Supporting health care Supporting health care professionals in professionals in

evaluating the quality of evaluating the quality of health educational health educational

materials for patient as a materials for patient as a new task for medical new task for medical librarians in Polandlibrarians in Poland

Ewa Dobrogowska-SchlebuschEwa Dobrogowska-Schlebusch

Medical Library, KrakówMedical Library, Kraków

►Patient education Patient education should be an should be an

integral part of any integral part of any healthcare services, healthcare services, as as being informed being informed about one's health about one's health

care options is care options is essential to a essential to a

patient's health and patient's health and well-being well-being

The values of patient education:The values of patient education:

►Reduces patients’ anxiety and depressionReduces patients’ anxiety and depression►Increases their knowledgeIncreases their knowledge►Prepares patients for a consultation with healthcare Prepares patients for a consultation with healthcare

professionalsprofessionals►Increases understanding of health problemIncreases understanding of health problem►Improves satisfaction, quality of life, psychological Improves satisfaction, quality of life, psychological

outcomes and adherence to treatment outcomes and adherence to treatment ►Reduces costs of medical care Reduces costs of medical care

BBenefits of healthenefits of health information conveyed in information conveyed in written form:written form:

►It reinforces and supplements information that is It reinforces and supplements information that is provided verballyprovided verbally

►Facilitates the memorization and recall of Facilitates the memorization and recall of informationinformation

►Consistency, reusability and portabilityConsistency, reusability and portability►It empowers patients to learn at their own pace It empowers patients to learn at their own pace

and enables them to choose the amount of and enables them to choose the amount of information that suits their information needsinformation that suits their information needs

►It is a cost-effective and time-efficient method of It is a cost-effective and time-efficient method of giving health messagesgiving health messages

In order to be In order to be effective written patient effective written patient educational materials should meet the educational materials should meet the

following criteria :following criteria :

►They should be based on scientific foundation, They should be based on scientific foundation, realistic and currentrealistic and current

►They should be readable, understandable They should be readable, understandable and easy to remember, especially for and easy to remember, especially for patients with low literacy skillspatients with low literacy skills

Could hospital and Could hospital and public health public health

librarians help librarians help health care health care

professionals in professionals in quality quality

assessment of assessment of patient patient

educational educational materials?materials?

Aims of the study:Aims of the study:

►To assess the To assess the suitability and readabilitysuitability and readability of written of written educational materials being used in particular educational materials being used in particular medical practice (Division of Pain Research and medical practice (Division of Pain Research and Treatment of the Jagiellonian University Hospital in Treatment of the Jagiellonian University Hospital in Kraków)Kraków)

►To help health care professionals from Division of To help health care professionals from Division of Pain Research and Treatment to choose the best Pain Research and Treatment to choose the best available materials for their patientsavailable materials for their patients

►To demonstrate how medical librarians could To demonstrate how medical librarians could support the process of patient education in polish support the process of patient education in polish hospitalshospitals

SuitabilitySuitability

ReadabilityReadability

Refers to how well the educational material could be understood and accepted by the reader

Refers to the reading difficulty of a resource

MethodsMethods

► The Suitability Assessment of the The Suitability Assessment of the materials (SAM) instrument materials (SAM) instrument was usedwas used to to

assess their suitability of health assess their suitability of health educational materials andeducational materials and Gunning-FOG Gunning-FOG formulaformula to assess their readability levelto assess their readability level

► SAM – the Suitability SAM – the Suitability Assessment of Materials Assessment of Materials instrument instrument

► - was developed in 1993 - was developed in 1993 by Leonard and Cecilia by Leonard and Cecilia Doak and Jane Root, Doak and Jane Root, leading experts in health leading experts in health education for adults under education for adults under the Johns Hopkins School of the Johns Hopkins School of Medicine Project. It is a Medicine Project. It is a part of following book:part of following book:

SAM rates materials on different factors SAM rates materials on different factors (22), grouped into six main categories:(22), grouped into six main categories:

* * ContentContent * Literacy Demand* Literacy Demand * Graphics* Graphics * Layout and Typography* Layout and Typography * Learning Stimulation and Motivation* Learning Stimulation and Motivation * Cultural Appropriateness* Cultural Appropriateness

► Each of the 22 items we rate on a scale of:Each of the 22 items we rate on a scale of:2 points - suitable2 points - suitable1 point - adequate 1 point - adequate 0 point - not suitable0 point - not suitableNA - not applicable NA - not applicable

► Applicable scores are summed and converted into a Applicable scores are summed and converted into a percentage. The percentage scores are interpretated as percentage. The percentage scores are interpretated as follows: follows:

0-39% = inadequate0-39% = inadequate40-69% = adequate40-69% = adequate70-100% = superior70-100% = superior

► Because the category of cultural appropriateness is not relevant Because the category of cultural appropriateness is not relevant to polish educational materials it was assessed in this studyto polish educational materials it was assessed in this study

Gunning-Fog formula was used to assess the Gunning-Fog formula was used to assess the readbility of the materialsreadbility of the materials

* * Gunning fog index is a test designed to measure the Gunning fog index is a test designed to measure the readability of a sample of writing. It can be calculated readability of a sample of writing. It can be calculated with the following algorithmwith the following algorithm

* The words which consist of 4 not of 3 words syllables * The words which consist of 4 not of 3 words syllables were considered as difficultwere considered as difficult

Results:►Only 12 printed patients educational materials were Only 12 printed patients educational materials were

collected in DPRT (IX 2009 – IV 2010) and assessed in collected in DPRT (IX 2009 – IV 2010) and assessed in this studythis study

►8 leaflets were scored as „superior”, 3 as „adequate” 8 leaflets were scored as „superior”, 3 as „adequate” and 1 as „not suitable” (Overall „SAM” score)and 1 as „not suitable” (Overall „SAM” score)

►All of the materials used some sort of advance All of the materials used some sort of advance organizers („road signs” such as headers and topic organizers („road signs” such as headers and topic captions, that briefly tells what is coming next)captions, that briefly tells what is coming next)

►Almost all of the materials were of superior quality in Almost all of the materials were of superior quality in terms of typography (n=11) and layout (n=11)terms of typography (n=11) and layout (n=11)

► In the majority (n=10) of the materials the purpose was In the majority (n=10) of the materials the purpose was either explicitly stated or impliedeither explicitly stated or implied

►Most of the materials (n=10) modeled specific user Most of the materials (n=10) modeled specific user behavior or skillbehavior or skill

But......But......

►Materials scored very poorly on readability, with 9 leaflets Materials scored very poorly on readability, with 9 leaflets scoring as „not suitable” and 3 scoring as „adequate”. None scoring as „not suitable” and 3 scoring as „adequate”. None of the materials was „superior” in terms of readabilityof the materials was „superior” in terms of readability

►Only two of materials have included some sort of Only two of materials have included some sort of interactive learning stimulation (problems or questions are interactive learning stimulation (problems or questions are presented for users response)presented for users response)

► 9 of the materials did not include a summary or review of 9 of the materials did not include a summary or review of the presented informationthe presented information

Characteristics of the best leaflet (Exercises Characteristics of the best leaflet (Exercises for thoracic and lumbar spine)for thoracic and lumbar spine) available available in DPRT (overall SAM score: 36 points = in DPRT (overall SAM score: 36 points =

90%):90%):

► „„adequate” literacy level (7adequate” literacy level (7ththgrade)grade)► throughout use of conversational throughout use of conversational

style, active voice and simple style, active voice and simple sentencesentence

► cover graphic presents the purpose cover graphic presents the purpose of the materials, other illustrations of the materials, other illustrations presented key messages visuallypresented key messages visually

► the purpose of the leaflet explicitly the purpose of the leaflet explicitly stated stated

► it models specific users behaviors it models specific users behaviors (exercises) (exercises)

► it is „superior” in terms of typography it is „superior” in terms of typography and layoutand layout

The drawbacks of the brochure („Relief in Pain”) produced The drawbacks of the brochure („Relief in Pain”) produced by the Polish Pain Society (overall „SAM” score = 55%)by the Polish Pain Society (overall „SAM” score = 55%)

► exceedingly high literacy demand exceedingly high literacy demand (16 th grade = level of academic (16 th grade = level of academic texts)texts)

► too difficult vocabulary and too difficult vocabulary and complex sentence with long complex sentence with long phrasesphrases

► nearly all topics focus on non-nearly all topics focus on non-behavior factsbehavior facts

► purpose is not explicitly statedpurpose is not explicitly stated► no interactive learning or no interactive learning or

stimulation is providedstimulation is provided► insufficient use of illustrationsinsufficient use of illustrations► no summary or review includedno summary or review included

The list of best five leaflets was created:

1. 90%

2. 82,5%

3. 79%

4. 77,50%

5. 76,50%

Limitations of the studyLimitations of the study::

► The study was carried out only on a very small sample of The study was carried out only on a very small sample of patient educational leaflets and on that basis it is not possible patient educational leaflets and on that basis it is not possible to draw conclusions about the general quality of leaflets that to draw conclusions about the general quality of leaflets that are offered in polish pain treatment clinics.are offered in polish pain treatment clinics.

► Limitations related to SAM instrument:Limitations related to SAM instrument:

* * SAM SAM does not evaluate materials in terms of their general quality, does not evaluate materials in terms of their general quality, scientific accuracy and completeness, but only in terms of their scientific accuracy and completeness, but only in terms of their suitability for patients with low literacy skillssuitability for patients with low literacy skills* It was not described neither in or* It was not described neither in oriiginal research nor in other ginal research nor in other publications how the SAM instrument was developed and evaluatedpublications how the SAM instrument was developed and evaluated* The authors of SAM instrument reported the validity of the instrument * The authors of SAM instrument reported the validity of the instrument (face validity), b(face validity), buut not the reliability of measuret not the reliability of measure

The importance of the researchThe importance of the research::

► it it could help health care professionals from Division of Pain could help health care professionals from Division of Pain Research and Treatment Research and Treatment to to choosechoose thethe most most suitable suitable materialsmaterials for for patientpatient educationeducation in their practicein their practice

► it could indicate which features should be taken into account it could indicate which features should be taken into account when designing patient educational materials to maximize when designing patient educational materials to maximize their effectivenesstheir effectiveness

► it helped to identify specific errors occurring in the brochure it helped to identify specific errors occurring in the brochure produced by the Polish Painproduced by the Polish Pain Society, which could impede its Society, which could impede its proper understanding proper understanding

► the study revealed, that to few patient educational materials the study revealed, that to few patient educational materials are produced in Poland. Some improvement is necessary to are produced in Poland. Some improvement is necessary to be done in this areabe done in this area

The new role of health librarianThe new role of health librarian

► Thanks to their expertise in area of health literacy, Thanks to their expertise in area of health literacy, medical librarians, especially those working in medical librarians, especially those working in hospitals, could play a very important role in hospitals, could play a very important role in supporting the process of patient education in a daily supporting the process of patient education in a daily medical practice by delivery of the high quality patient medical practice by delivery of the high quality patient educational materialseducational materials

► They could also support the process of evaluation of They could also support the process of evaluation of patient educational materials patient educational materials

► They could refer the health care professionals to other They could refer the health care professionals to other quality assessment instruments which could enable quality assessment instruments which could enable the judgment of the materials in terms of their general the judgment of the materials in terms of their general quality.quality.

Thank you very much for Thank you very much for your attention!your attention!

ewa.dobrogowska-schlebusch@uj.edu.pl