- Email: [email protected]
Assessing the readability of skin care and pressure ulcer patient education materials
WOUND CARE SECTION EDITOR: Barbara Pieper, PhD, RN, CS, CWOCN, FAAN
Assessing the Readability of Skin Care and Pressure Ulcer Patient Education Materials Feleta L. Wilson, PhD, RN, and Barbara N. Williams, MSN, RN
Objective: The purpose of this study was to evaluate the readability of written patient education materials used to teach patients about the prevention and care of skin and pressure ulcers. Other design characteristics of the materials including organization, writing style, appearance, and appeal also were assessed. Design: This study used a nonexperimental, descriptive design. Setting and stimulus materials: Ten pamphlets and brochures commonly used in urban hospitals, home care agencies, and public clinics in the Midwest were evaluated. Instruments: The study used 2 instruments: The Area Health Education Center (AHEC) checklist and the Simple Measure of Gobbledygook (SMOG) readability formula. Methods: The investigator used the SMOG readability formula to analyze patient education materials. The AHEC checklist was used to evaluate the design characteristics of the materials, including organization, writing style, appeal, and appearance. Results: The overall readability level of the written materials was 10th grade. At least half of the materials were written at 8th-grade level or below, which is considered acceptable for the general public. Some pamphlets used words such as “seborrheic keratosis” or “actinic keratosis,” making the materials difficult to read. An incidental finding was that none of the materials addressed skin care or pressure ulcer experiences of different cultural groups. Conclusion: None of the materials was determined to be appropriate teaching tools for low-literacy patients, as measured by the AHEC checklist. Although half the materials were written at the 8thgrade level and below, that level may be too high for many patients. (J WOCN 2003;30:224-30.) Feleta L. Wilson, PhD, RN, is Associate Professor, College of Nursing, Wayne State University, Detroit, Michigan. Barbara N. Williams, MSN, RN, is Senior Lecturer, College of Nursing, Wayne State University, Detroit, Michigan. Reprint requests: Feleta L. Wilson, PhD, RN, 19371 Chapel, Detroit, MI 48219; e-mail: [email protected]. Copyright © 2003 by the Wound, Ostomy and Continence Nurses Society. 1071-5754/2003/ $30.00 + 0 doi:10.1067/mjw.2003. 137
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o effectively participate in decisions about their health care, patients must have access to information that they can read and understand, especially in the areas of prevention and management of wounds or pressure ulcers. According to Pieper and colleagues,1 much of the treatment of wounds is provided in the home by family members. The foreign experience of wound care means that the families rely on written and verbal support from health care professionals. Although written information is available to health care consumers, many patients and families will not benefit from these resources if they cannot read or comprehend them.2 In spite of the knowledge that a significant number of the nation’s adults have low literacy skills, there is limited research on the appropriateness of written materials used to teach patients about their pressure ulcers. Accordingly, the purposes of this article are to: (1) assess the readability of selected written patient education and instructional materials used to teach patients about skin and pressure ulcers care, (2) evaluate the design characteristics of written materials including organization, writing style, appearance, and ap-
peal, and (3) discuss steps WOC nurses can use to develop their own easy-to-read patient education materials. The care of pressure ulcers often places a financial strain on patients. High medical costs, special supplies, equipment, and products, the threat of exceeding allowable insurance coverage, and medical regimes of special diets that may not be within the family budget cause undue hardships.3 Effective patient education strategies have the potential to improve wound care treatment, prevent further problems, reduce hospital stay, minimize recidivism, and reduce knowledge barriers.
LITERATURE REVIEW Low Literacy and Health Care The problem of low literacy levels among adults was reported in the National Adults Literacy Survey (NALS).4 The results of the study revealed that nearly half the adults in the United States had less than acceptable reading skills. The NALS findings were based on an English proficiency scale that assessed 3 dimensions of literacy: prose literacy (ability to under-
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stand simple prose and editorials), document literacy (ability to understand graphs, maps, and schedules), and quantities literacy (ability to perform simple arithmetic operations). The proficiency scale ranged from level 1 (lowest literacy level) to level 5 (highest literacy level). For example, to measure quantitative literacy at level 1, participants were asked to complete a deposit slip for a bank auto-teller machine by calculating the total amount to be deposited and entering the amount in the space next to the word TOTAL. A more complex task was required at level 5. At this level, the study participants were asked to read an advertisement for a home equity loan. By using the information available, they were asked to explain how they would calculate the total amount of interest charges with the loan. Only 4% of the adult population was able to perform at level 5 on the quantitative literacy proficiency scale. Low literacy knows no boundaries, but studies have shown that poor readers are likely to reside in urban setting, are poor, poorly educated, elderly, and often are members of minority groups.4,5 Patients with low literacy levels do not readily participate in health care and when they do seek services, they are hampered by limited reading and comprehension skills, which may result in inadequate access to the existing health care system.6,7 Patients with poor reading skills have difficulty reading a thermometer, discharge instruction forms, informed consent forms, and medication labels. Frequently, patients who have pressure ulcers are elderly, a population group with a disproportionately low reading ability. In fact, the NALS pointed out that older adults demonstrated poor literacy proficiency in all 3 dimensions (prose, document, and quantitative literacy).4 In addition, the age-associated conditions of poor visual acuity, diminishing cognitive abilities, and deficits in hearing make comprehension of basic information more difficult.
Patient Education and Low Literacy Changes in health care delivery make patient education the likely cornerstone for bridging some of the gaps in patient understanding. Patient education is more than disseminating information. A primary goal is to increase knowledge so patients can better cope with their illnesses. Appropriate teaching can eliminate knowledge deficits about medications, dietary requirement, surgical procedures, and skin and wound care. Unfortunately, traditional teaching techniques have been ineffective and incongruent with the learning skills and needs of low-literacy patients. A lack of basic literacy is a barrier to participating in health and can interfere with the patient’s ability to learn. The ability to read and comprehend information is crucial to maneuver within the health care system.
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Despite evidence that suggests that many written patient education brochures, pamphlets, and handouts are a mismatch between the literacy requirements of the materials and the reading skills of the patients, nurses continue to rely heavily on them as a major source of instruction and information.8 One in 5 Americans reads at the fifth-grade level or below, yet some written materials require literacy skills 2 to 3 grades higher than the patient’s reading level.4 Most literacy experts recommend no higher than an 8th-grade reading level for written materials for the general public,9,10 and an even lower reading level in some environments.7 When patients have difficulty reading and understanding information, serious and costly consequences can occur.11 Any tools and interventions used by the nurse to improve understanding must be clear and concise.
Readability Formulas To determine the reading levels of written information, health care providers use readability formulas to analyze the documents. Readability formulas are objective quantities tools that estimate the reading difficulty of a passage. This estimate of reading difficulty is based on the lengths of sentences and number of polysyllabic words used in a sentence. The estimates of reading difficulty provide a score or index number that indicates how readable the text is. Although readability formulas are valid and are used frequently in research,12 critics cite several shortcomings from their use. These formulas do not consider such factors as format, layout, complexity of the subject, familiarity of the reader with the subject, or reader interest.7,12,13 More than 40 readability formulas exist, such as the Fry,14 Flesch-Kincaid,15 and Simple Measure of Gobbledygook (SMOG),16 which are used extensively in health care. The Fry index measures the average number of syllables and sentences per 100 words and uses a Fry Readability Estimate Graph to determine a readability level. The scores on this measure range from a low of 1st grade to a high of graduate school. The Flesch-Kincaid formula17 is the following equation to determine readability: 0.39 × the average number of words per sentence + 11.8 × the average number of syllables per word – 15.59. A computerized version of the Flesch-Kincaid formula is located on the Microsoft Word for Windows 2000 (Version 7.0)18 word processing package. Meade and Smith13 found that the Fry and the Flesch formulas have strong correlations when used with health-based information (r = 0.91 to 0.95). The SMOG is one of the easiest formulas to use.19 The evaluator selects 30 sentences from the material, preferably 10 consecutive sentences from the beginning, middle, and end of the document. From the entire 30 sentences, the evaluator counts
A lack of basic literacy is a barrier to participating in health and can interfere with the patient’s ability to learn.
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Box 1 Area Health Education Center Assessment Checklist Title of material: __________________________________________ Directions: Place a check next to each item that meets the described attribute. ORGANIZATION
1. 2. 3. 4. 5.
The cover is attractive. It indicates the core content and intended audience. Desired behavior changes are stressed.“Need to know” information is stressed. No more than 3 or 4 main points are presented. Headers and summaries are used to show organization and provide message repetition. A summary that stresses what to do is included.
WRITING STYLE
To effectively participate in decisions about their health care, patients must have access to information that they can read and understand, especially in the areas of prevention and management of wounds or pressure ulcers.
6. The writing is in conversational style, active voice. 7. Little or no technical jargon is used. 8. The text is vivid and interesting. The tone is friendly. APPEARANCE
9. 10. 11. 12. 13. 14.
Pages or sections appear uncluttered; ample white space is used. Lowercase letters are used (capitals are used only where grammatically needed). There is a high degree of contrast between the print and the paper. The print size is at least 12 points, serif type, and no stylized letters are used. Illustrations are simple—preferably line drawings. Illustrations serve to amplify the text.
APPEAL
15. The material is culturally, gender, and age appropriate. 16. The material closely matches the logic, language, and experience of the intended audience.
17. Interaction is invited via questions, responses, suggested action, etc. Used with the permission of S. Plimpton-Stableford. Health Literacy Program, Area Health Education Center of Maine, University of New England.
the total number of words that contain 3 or more syllables. The total number of multisyllabic words are used with a conversation table for the SMOG to obtain a grade level equivalence.16 Ayello20 used 2 readability formulas to assess the appropriateness of a patient’s booklet on the care of pressure ulcers released by the Agency for Healthcare Research Quality (AHRQ), formerly the Agency for Health Care Policy and Research (AHCPR). In this evaluation, she used criteria suggested by Falvo,21 Gunning-Fog readability formula,22 and the SMOG procedure.13 Ayello found that the booklet met many of the criteria for written education materials such as using white background and black lettering for easier reading, using a conversational writing style, and having accurate and reliable information. However, she found that the readability of 9th grade was too high, some of the illustrations were confusing, and the type size of 10 to 12 points was too small. Later, Ayello23 evaluated a revised version of the same booklet and found significant improvements, but the readability was above the 8th-grade level.
ness of other important design factors of written materials and developed an assessment checklist. An example of the AHEC assessment checklist is displayed in Box 1. The AHEC checklist measures the factors of organization, writing style, appearance, and appeal. Organization assesses whether the “need to know” information is presented at the beginning of the written material, if the materials contained headers and summarized the information, and if the summary explained the expected patient behavior. Writing style evaluates whether the materials are written in conversation voice and assesses if the use of medical jargon is limited. The third characteristic, appearance, considers whether illustrations used in the material are appropriate and clearly convey the intended message, if the type size is at least 12 points, and if there is ample white space on the pages of the documents. Finally, appeal determines if the material is gender, culturally, and age appropriate and whether the material is interactive. Both the SMOG and the AHEC checklist are highly recommended by literacy experts.2,7,24
Design Factors of Written Patient Education Material
Research Questions
The literacy experts at the Maine Area Health Education Center (AHEC)2,7,24 recognized the need for a practical tool to assess the appropriate-
This study addressed the following questions: 1. What is the readability of written patient education materials on skin care and pressure ulcers as measured by the SMOG?
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Table. Readability scores of skin and pressure ulcer patient education materials as measured by the SMOG Patient education Skin health Diabetes Foot Care Patient and Family Pressure Ulcer Prevention Caregiving: Compression, Loving, Coping Wound Care: Cleaning, Treatment, Dressing You’re Not Alone: Understanding Pressure Ulcers Pressure Ulcers: Your Role in Prevention and Treatment Skin Care: Protection, Prevention, Improvement Bed Sores* Nutrition and Wounds*
Source
Readability scores
Krames Communication, The Stay Well Company, 415-994-8800 Pritchetti & Hull Associates, http://www.p-h.com/ Gaymar Industries
7th 10th
KimCare, 1-800-789-4495
13th
KimCare
10th
Wound Care Direct.com, www.WoundCareDirect.com Krames Communication
10th 11th
KimCare
10th
John D. Dingell VA Medical Center, Detroit, Mich John D. Dingell VA Medical Center, Detroit, Mich
9th
8th 8th
*SMOG short version.
2. Are the characteristics of organization, writing style, appearance, and appeal of these materials, measured by the AHEC checklist, appropriate for patients with low literacy skills?
METHODS Research Design The study used a nonexperimental, descriptive design to examine the readability and appropriateness of patient education materials focused on skin care and pressure ulcers.
properties for the AHEC checklist are not yet available. The SMOG12 is a manually computed readability formula commonly used in health care. There are 2 versions of this formula: a regular version for evaluating written materials that contain 30 or more sentences and a short version for evaluating materials that contain less than 30 sentences. The SMOG was selected because it is accurate and correlates highly with other readability formulas (FOG, r = 0.99, and Fry, r = 0.93).7,13
Procedure Setting and Education Materials Ten patient education materials were evaluated (see the Table). These educational materials were commonly used in acute care hospitals, home care, and public clinics in an urban environment in the Midwest.
Instruments Two instruments were used in this study: the SMOG16 and the AHEC checklist.24 The AHEC checklist assessed organization, writing style, appearance, and appeal of the materials. Any item in the checklist that was not addressed in the material indicated that the materials were likely to be inappropriate for low-literacy patients. To obtain inter-rater reliability, 2 evaluators independently assessed the appropriateness of each of the 10 educational materials and reached a 90% agreement in the evaluation. In essence, 9 out of 10 times, the raters agreed on the evaluation. Psychometric
A convenience sample of written patient education materials (N = 10) were evaluated for their readability. These materials were selected because nurses in an urban ambulatory clinic commonly used them as primarily teaching tools. The AHEC checklist was used to evaluate the characteristics of organization, writing style, appeal, and appearance and the SMOG.
RESULTS Readability Results of Patient Education Materials The overall readability for the patient education materials on skin and pressure ulcers was 10th grade (SD = 1.71). The scores ranged from a low of 7th grade for information in the pamphlet titled “Diabetes Foot Care” to a high of 13th grade for the brochure “Caregiving: Compression, Loving, Coping.” Five of the materials were higher than the 8th-grade level and 5 were at or below the recom-
The study used a nonexperimental, descriptive design to examine the readability and appropriateness of patient education materials focused on skin care and pressure ulcers.
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Box 2 Developing easy-to-read written patient education materials Do: 1. Match education materials with the characteristics of the target reader (ie, age, gender, ethnicity). 2. Use a minimum number of medical terms and jargon. 3. Use drawings or pictures that are appropriate and convey the message. 4. Make sure the material is written at the appropriate reading level of the anticipated reader. 5. Check the readability of the material for reader appropriateness. 6. Make materials simple, concise, and easy to follow. 7. At the beginning phase, seek input from people for whom the information is targeted. Don’t:
Although experts suggest that readability at the 8th grade level and below is acceptable for the general public,9,10 that level may still be too high for many patients who are poorly educated, elderly, and reside in urban areas.
1. Write materials using the passive voice. 2. Crowd the page with lots of words and pictures. 3. Develop one-size-fits-all written patient education materials.
mended level, placing them at an appropriate reading level for many patients to understand the information (see the Table).
Results of the AHEC Checklist Evaluation Organization. The majority of the pamphlets and brochures presented the “need to know” information either at the middle or at the end. Eighty percent of the documents were commercially developed with attractive, colorful covers. A majority of the materials used headers to guide the reader but seldom summarized the information or emphasized the expected health behavior of the reader. Writing style. The writing style of the materials consisted mostly of passive voice rather than the recommended conversation of active voice. Some of the words in the pamphlets such as “seborrheic keratosis” or “actinic keratosis” made the materials difficult to read; however, the majority of the materials used simple words and minimal medical terminology. Appearance. The print size of the materials ranged from a low of 11 points to a high of 14 points. Some of the illustrations were simple and clearly conveyed the message; other illustrations were extremely complex with difficult anatomic drawings of the layers of the skin, circulation system, and nervous system. Appeal. Although the materials were used in diverse populations, none addressed cultural needs of the patients. One brochure displayed a picture of a person of color on the cover, but the information contained within the text was generic. In fact, none of the materials specifically addressed the experiences of caring for pressure ulcers from a cultural perspective.
DISCUSSION This study examined the readability and design characteristics of skin and pressure ulcer patient
education materials. One limitation of this study is the small sample size, which limits the generalizability of the results to the materials in this study. Even though half the materials had acceptable readability levels, none of the brochures met both the readability level and each attribute criterion of AHEC, making them inappropriate as teaching tools for low-literacy patients. Although experts suggest that readability at the 8th-grade level and below is acceptable for the general public,9,10 that level may still be too high for many patients who are poorly educated, elderly, and reside in urban areas. For these patients, Doak and colleagues7 recommended between a 3rd- and 5th-grade readability level. The lack of available easy-to-read health information and education materials for disadvantaged patients increases barriers to care and prevents consumers from making informed choices. When a limited amount of patient education materials is available or the available materials are inappropriate, the WOC nurse can develop pamphlets and brochures to meet the needs of a target audience. Desktop publishing, clip art, and computer programs are helpful in this endeavor. Computer programs contained in Microsoft Word for Windows18 such as “Art Clip” and “Word Art” are tools that can be used to develop materials economically and yield a product that is appealing, well organized, and appropriate. A starting point would be to determine learning objectives for the intended reader. Next, a brief outline of the information to be included in the materials should be written. The “need to know” information or expected patient behavior must be placed at the beginning of the materials. For example, a pamphlet about keeping the skin clean would begin with a section on “Steps to Keeping the Skin Clean—Step 1.” The materials must be written simply and clearly. Well-placed illustrations or simple drawings that depict the steps of keeping skin clean will
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KEY POINTS • One in 5 Americans reads at the 5th-grade level or below. • Some written education materials require literacy skills 2 to 3 grades higher than the patient’s reading level. • WOC nurses must understand how to choose or develop written materials that are congruent with the reading skills of their patients.
help the reader. Sentences should be short, contain limited medical terms, and be written in conversational style or active voice rather than passive voice. For example, “Patients are advised to keep skin clean and lubricated” is in the passive voice, whereas “Keep your skin clean and lubricated” is written in the conversational voice. Short sentences in the conversational voice enhance comprehension. It is recommended that only 3 to 4 main points be on a page and that paragraphs preferably be presented in bullet formation. The writer should refrain from using all UPPERCASE letters, because this practice makes it difficult for the reader to follow the text.17 Some of the key points for developing easy-to-read materials are presented in Box 2. Several publications in the literature can guide the WOC nurse in selecting and/or developing easy-to-read materials.7,24-28 These materials should be tested with potential readers early in the developmental phase to determine if the information is comprehendible. Osborne29 recommended testing materials using focus groups or simply getting feedback from 10 to 20 patients before use. WOC nurses must understand how to choose written materials that are congruent with the reading skills of their patients. During the initial nursing assessment, a measure that evaluates reading comprehension can be given to the patient. Because of the shame and embarrassment associated with low literacy, it is unlikely that patients will volunteer this information. One reading test widely used in health care is the Rapid Estimate of Adult Literacy in Medicine.30 This test is a userfriendly word recognition test than can be administered in a clinical setting, is not intimidating for the WOC nurse, and usually can be completed in 10 minutes. WOC nurses are encouraged to be sensitive during the interview and make the patient as comfortable as possible. Written information should complement verbal teaching and should not be a replacement for faceto-face patient education. While the discussion of health care delivery for this vulnerable populations grows, WOC nurses are encouraged to take an active leadership role in developing educational strategies that meet the needs of patients who cannot read and have pressure ulcers. Some of the ways in which nurses can have an active role
is to (1) write letters to the publisher of patient education materials regarding their strengths and weaknesses, (2) participate on committees that develop or choose materials used by the health organization, and (3) participate in the field testing of these materials. REFERENCES 1. Pieper B, Templin T, Dobal M. Wound prevalence, type, and treatment in home care. Adv Wound Care 1999;12:117-26. 2. Wilson FL. Are patient information materials too difficult to read? Home Healthcare Nurs 2000;18:10715. 3. Xakellis G. Cost of pressure ulcer prevention in longterm care. Adv Wound Care 1998;1:22-9. 4. Kirsch IS, Jungleblut A, Jenkins L, Kolstead A. Adult literacy in America: national adult literacy survey. Washington: National Center for Education Statistics, US Department of Education; 1993. 5. Weiss B, Hart G, Pust R. The relationship between literacy and health. J Health Care Poor Underserved 1993;1:351-61. 6. Wilson FL, Baker L, Syed-Brown C, Gollop C. Readability of cancer patient education information found on CancerNet. Oncol Nurs Forum 2000;27: 1403-9. 7. Daok LC, Doak CC, Root J. Teaching patients with low-literacy skills. Philadelphia: Lippincott; 1996: p. 3-15, 40-57. 8. Redman B. The practice of patient education. 8th ed. St. Louis: Mosby; 2001: p. 50-67. 9. Estey A, Musseau A, Keehn L. Patient’s understanding of health information: a multihospital comparison. Patient Educ Couns 1994;1:73-8. 10. Streiff L. Can clients understand instruction? J Nurs Scholarsh 1986;18:48-52. 11. Pfizer Health Literacy Initiative. “Health Literacy: Leading Edge Practices.” September 18-19, 2002; Washington, DC. 12. Contreras A, Garcia-Alonso R, Echenique M, DaveContreras F. The SOL formulas for converting SMOG readability scores between health education materials in Spanish, English, and French. J Health Commun 1999;4:21-9. 13. Meade C, Smith C. Readability formulas: caution and criteria. Patient Educ Couns 1991;17:153-8. 14. Fry E.Fry readability graph: clarification,validity,and extension to level 17. J Reading 1977;21:242-52. 15. Flesch R.A new readability yardstick. J Appl Psychol 1948;32:221-3. 16. McLaughlin HG. SMOG: Grade a new readability formula. J Reading 1969;12:641-6.
Written information should complement verbal teaching and should not be a replacement for face-toface patient education.
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17. Klare G. Readability. In: Person PD, editor. Handbook of reading research. New York: Longman; 1984: p. 681-774. 18. Microsoft Corporation. A guide for Microsoft Word for Windows 2000. Redmond (WA): Microsoft Corporation; 2000. 19. Ley P, Florio T. The use of readability formulas in health care. Psychol Health Med 1996;1:7-28. 20. Ayello E. A critique of the AHCPR’s “preventing pressure ulcers—a patient’s guide” as a written instructional tools. Decubitus 1993;6:44-50. 21. Falvo D. Effective patient education: a guide to increase compliance. Rockville (MD): Aspen; 1985. 22. Gunning R. The FOG index after twenty years. J Bus Commun 1968;6:3-13. 23. Ayello E. Critique of AHCPR’s consumer guide “Treating pressure sores.” Adv Wound Care 1995; 8:19-32. 24. Plimpton S, Root J. Materials and strategies that work in low literacy health communication. Public Health Rep 1994; 109:866-91.
25. Wilson FL. The suitability of United States pharmacopoeia dispensary drug leaflets for urban psychotropic patients with limited reading skills. Arch Psychiatr Nurs 1999;13:204-11. 26. Horner SD, Surratt D, Juliusson S. Improving readability of patient education materials. J Community Health Nurs 2000;17:15-23. 27. Walsh D, Shaw D. The design of written information for cardiac patients: a review of the literature. J Clin Nurs 2000;9:658-67. 28. Wilson FL. Evaluation of education materials using Orem’s self-care deficit theory. Nurs Sci Q 2003; 16:68-76. 29. Osborne H. In other words…can they understand? Testing patient education materials with intended readers [online]. Available from: URL: http://www. healthliteracy.com/oncallnov2001.html 30. Murphy P, Davis T, Long S, Jackson R, Jackson B. Rapid estimate of adult literacy in medicine. J Reading 1993;37:123-30.
Publisher’s Award for Original Research The Publisher’s Manuscript Award for Original Research is awarded to the author(s) of a manuscript that makes a significant contribution to WOC nursing. This award is designed to recognize excellence in the field. Manuscripts will be judged for their scholarship, originality, and relevance to WOC nursing. All manuscripts that are published within a volume (calendar year) and meet the eligibility requirements are evaluated for the award, which is presented at the WOCN Annual Conference the following spring. In the event an insufficient number of manuscripts are published within a volume, those published manuscripts will be held for consideration for the award the following year. The award is composed of an honorarium in the amount of $500 and a plaque. The check is issued in the name of the corresponding author, and the plaque includes the names of all authors. The eligibility requirements are as follows: Research report must be original and not published or submitted for publication elsewhere. Manuscript must be 2000 words or more. It is not necessary to be a member of the WOCN or have graduated from a WOCN Educational Program or an ET Nursing Education Program to compete for the award. The manuscript cannot be authored by any member of the Editorial Board. All eligible manuscripts are evaluated by the Journal’s Editorial Board.
This award is funded by the Journal of WOCN and Mosby, Inc.
Assessing the Readability of Skin Care and Pressure Ulcer Patient Education Materials Feleta L. Wilson, PhD, RN, and Barbara N. Williams, MSN, RN
Objective: The purpose of this study was to evaluate the readability of written patient education materials used to teach patients about the prevention and care of skin and pressure ulcers. Other design characteristics of the materials including organization, writing style, appearance, and appeal also were assessed. Design: This study used a nonexperimental, descriptive design. Setting and stimulus materials: Ten pamphlets and brochures commonly used in urban hospitals, home care agencies, and public clinics in the Midwest were evaluated. Instruments: The study used 2 instruments: The Area Health Education Center (AHEC) checklist and the Simple Measure of Gobbledygook (SMOG) readability formula. Methods: The investigator used the SMOG readability formula to analyze patient education materials. The AHEC checklist was used to evaluate the design characteristics of the materials, including organization, writing style, appeal, and appearance. Results: The overall readability level of the written materials was 10th grade. At least half of the materials were written at 8th-grade level or below, which is considered acceptable for the general public. Some pamphlets used words such as “seborrheic keratosis” or “actinic keratosis,” making the materials difficult to read. An incidental finding was that none of the materials addressed skin care or pressure ulcer experiences of different cultural groups. Conclusion: None of the materials was determined to be appropriate teaching tools for low-literacy patients, as measured by the AHEC checklist. Although half the materials were written at the 8thgrade level and below, that level may be too high for many patients. (J WOCN 2003;30:224-30.) Feleta L. Wilson, PhD, RN, is Associate Professor, College of Nursing, Wayne State University, Detroit, Michigan. Barbara N. Williams, MSN, RN, is Senior Lecturer, College of Nursing, Wayne State University, Detroit, Michigan. Reprint requests: Feleta L. Wilson, PhD, RN, 19371 Chapel, Detroit, MI 48219; e-mail: [email protected]. Copyright © 2003 by the Wound, Ostomy and Continence Nurses Society. 1071-5754/2003/ $30.00 + 0 doi:10.1067/mjw.2003. 137
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o effectively participate in decisions about their health care, patients must have access to information that they can read and understand, especially in the areas of prevention and management of wounds or pressure ulcers. According to Pieper and colleagues,1 much of the treatment of wounds is provided in the home by family members. The foreign experience of wound care means that the families rely on written and verbal support from health care professionals. Although written information is available to health care consumers, many patients and families will not benefit from these resources if they cannot read or comprehend them.2 In spite of the knowledge that a significant number of the nation’s adults have low literacy skills, there is limited research on the appropriateness of written materials used to teach patients about their pressure ulcers. Accordingly, the purposes of this article are to: (1) assess the readability of selected written patient education and instructional materials used to teach patients about skin and pressure ulcers care, (2) evaluate the design characteristics of written materials including organization, writing style, appearance, and ap-
peal, and (3) discuss steps WOC nurses can use to develop their own easy-to-read patient education materials. The care of pressure ulcers often places a financial strain on patients. High medical costs, special supplies, equipment, and products, the threat of exceeding allowable insurance coverage, and medical regimes of special diets that may not be within the family budget cause undue hardships.3 Effective patient education strategies have the potential to improve wound care treatment, prevent further problems, reduce hospital stay, minimize recidivism, and reduce knowledge barriers.
LITERATURE REVIEW Low Literacy and Health Care The problem of low literacy levels among adults was reported in the National Adults Literacy Survey (NALS).4 The results of the study revealed that nearly half the adults in the United States had less than acceptable reading skills. The NALS findings were based on an English proficiency scale that assessed 3 dimensions of literacy: prose literacy (ability to under-
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stand simple prose and editorials), document literacy (ability to understand graphs, maps, and schedules), and quantities literacy (ability to perform simple arithmetic operations). The proficiency scale ranged from level 1 (lowest literacy level) to level 5 (highest literacy level). For example, to measure quantitative literacy at level 1, participants were asked to complete a deposit slip for a bank auto-teller machine by calculating the total amount to be deposited and entering the amount in the space next to the word TOTAL. A more complex task was required at level 5. At this level, the study participants were asked to read an advertisement for a home equity loan. By using the information available, they were asked to explain how they would calculate the total amount of interest charges with the loan. Only 4% of the adult population was able to perform at level 5 on the quantitative literacy proficiency scale. Low literacy knows no boundaries, but studies have shown that poor readers are likely to reside in urban setting, are poor, poorly educated, elderly, and often are members of minority groups.4,5 Patients with low literacy levels do not readily participate in health care and when they do seek services, they are hampered by limited reading and comprehension skills, which may result in inadequate access to the existing health care system.6,7 Patients with poor reading skills have difficulty reading a thermometer, discharge instruction forms, informed consent forms, and medication labels. Frequently, patients who have pressure ulcers are elderly, a population group with a disproportionately low reading ability. In fact, the NALS pointed out that older adults demonstrated poor literacy proficiency in all 3 dimensions (prose, document, and quantitative literacy).4 In addition, the age-associated conditions of poor visual acuity, diminishing cognitive abilities, and deficits in hearing make comprehension of basic information more difficult.
Patient Education and Low Literacy Changes in health care delivery make patient education the likely cornerstone for bridging some of the gaps in patient understanding. Patient education is more than disseminating information. A primary goal is to increase knowledge so patients can better cope with their illnesses. Appropriate teaching can eliminate knowledge deficits about medications, dietary requirement, surgical procedures, and skin and wound care. Unfortunately, traditional teaching techniques have been ineffective and incongruent with the learning skills and needs of low-literacy patients. A lack of basic literacy is a barrier to participating in health and can interfere with the patient’s ability to learn. The ability to read and comprehend information is crucial to maneuver within the health care system.
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Despite evidence that suggests that many written patient education brochures, pamphlets, and handouts are a mismatch between the literacy requirements of the materials and the reading skills of the patients, nurses continue to rely heavily on them as a major source of instruction and information.8 One in 5 Americans reads at the fifth-grade level or below, yet some written materials require literacy skills 2 to 3 grades higher than the patient’s reading level.4 Most literacy experts recommend no higher than an 8th-grade reading level for written materials for the general public,9,10 and an even lower reading level in some environments.7 When patients have difficulty reading and understanding information, serious and costly consequences can occur.11 Any tools and interventions used by the nurse to improve understanding must be clear and concise.
Readability Formulas To determine the reading levels of written information, health care providers use readability formulas to analyze the documents. Readability formulas are objective quantities tools that estimate the reading difficulty of a passage. This estimate of reading difficulty is based on the lengths of sentences and number of polysyllabic words used in a sentence. The estimates of reading difficulty provide a score or index number that indicates how readable the text is. Although readability formulas are valid and are used frequently in research,12 critics cite several shortcomings from their use. These formulas do not consider such factors as format, layout, complexity of the subject, familiarity of the reader with the subject, or reader interest.7,12,13 More than 40 readability formulas exist, such as the Fry,14 Flesch-Kincaid,15 and Simple Measure of Gobbledygook (SMOG),16 which are used extensively in health care. The Fry index measures the average number of syllables and sentences per 100 words and uses a Fry Readability Estimate Graph to determine a readability level. The scores on this measure range from a low of 1st grade to a high of graduate school. The Flesch-Kincaid formula17 is the following equation to determine readability: 0.39 × the average number of words per sentence + 11.8 × the average number of syllables per word – 15.59. A computerized version of the Flesch-Kincaid formula is located on the Microsoft Word for Windows 2000 (Version 7.0)18 word processing package. Meade and Smith13 found that the Fry and the Flesch formulas have strong correlations when used with health-based information (r = 0.91 to 0.95). The SMOG is one of the easiest formulas to use.19 The evaluator selects 30 sentences from the material, preferably 10 consecutive sentences from the beginning, middle, and end of the document. From the entire 30 sentences, the evaluator counts
A lack of basic literacy is a barrier to participating in health and can interfere with the patient’s ability to learn.
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Box 1 Area Health Education Center Assessment Checklist Title of material: __________________________________________ Directions: Place a check next to each item that meets the described attribute. ORGANIZATION
1. 2. 3. 4. 5.
The cover is attractive. It indicates the core content and intended audience. Desired behavior changes are stressed.“Need to know” information is stressed. No more than 3 or 4 main points are presented. Headers and summaries are used to show organization and provide message repetition. A summary that stresses what to do is included.
WRITING STYLE
To effectively participate in decisions about their health care, patients must have access to information that they can read and understand, especially in the areas of prevention and management of wounds or pressure ulcers.
6. The writing is in conversational style, active voice. 7. Little or no technical jargon is used. 8. The text is vivid and interesting. The tone is friendly. APPEARANCE
9. 10. 11. 12. 13. 14.
Pages or sections appear uncluttered; ample white space is used. Lowercase letters are used (capitals are used only where grammatically needed). There is a high degree of contrast between the print and the paper. The print size is at least 12 points, serif type, and no stylized letters are used. Illustrations are simple—preferably line drawings. Illustrations serve to amplify the text.
APPEAL
15. The material is culturally, gender, and age appropriate. 16. The material closely matches the logic, language, and experience of the intended audience.
17. Interaction is invited via questions, responses, suggested action, etc. Used with the permission of S. Plimpton-Stableford. Health Literacy Program, Area Health Education Center of Maine, University of New England.
the total number of words that contain 3 or more syllables. The total number of multisyllabic words are used with a conversation table for the SMOG to obtain a grade level equivalence.16 Ayello20 used 2 readability formulas to assess the appropriateness of a patient’s booklet on the care of pressure ulcers released by the Agency for Healthcare Research Quality (AHRQ), formerly the Agency for Health Care Policy and Research (AHCPR). In this evaluation, she used criteria suggested by Falvo,21 Gunning-Fog readability formula,22 and the SMOG procedure.13 Ayello found that the booklet met many of the criteria for written education materials such as using white background and black lettering for easier reading, using a conversational writing style, and having accurate and reliable information. However, she found that the readability of 9th grade was too high, some of the illustrations were confusing, and the type size of 10 to 12 points was too small. Later, Ayello23 evaluated a revised version of the same booklet and found significant improvements, but the readability was above the 8th-grade level.
ness of other important design factors of written materials and developed an assessment checklist. An example of the AHEC assessment checklist is displayed in Box 1. The AHEC checklist measures the factors of organization, writing style, appearance, and appeal. Organization assesses whether the “need to know” information is presented at the beginning of the written material, if the materials contained headers and summarized the information, and if the summary explained the expected patient behavior. Writing style evaluates whether the materials are written in conversation voice and assesses if the use of medical jargon is limited. The third characteristic, appearance, considers whether illustrations used in the material are appropriate and clearly convey the intended message, if the type size is at least 12 points, and if there is ample white space on the pages of the documents. Finally, appeal determines if the material is gender, culturally, and age appropriate and whether the material is interactive. Both the SMOG and the AHEC checklist are highly recommended by literacy experts.2,7,24
Design Factors of Written Patient Education Material
Research Questions
The literacy experts at the Maine Area Health Education Center (AHEC)2,7,24 recognized the need for a practical tool to assess the appropriate-
This study addressed the following questions: 1. What is the readability of written patient education materials on skin care and pressure ulcers as measured by the SMOG?
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Table. Readability scores of skin and pressure ulcer patient education materials as measured by the SMOG Patient education Skin health Diabetes Foot Care Patient and Family Pressure Ulcer Prevention Caregiving: Compression, Loving, Coping Wound Care: Cleaning, Treatment, Dressing You’re Not Alone: Understanding Pressure Ulcers Pressure Ulcers: Your Role in Prevention and Treatment Skin Care: Protection, Prevention, Improvement Bed Sores* Nutrition and Wounds*
Source
Readability scores
Krames Communication, The Stay Well Company, 415-994-8800 Pritchetti & Hull Associates, http://www.p-h.com/ Gaymar Industries
7th 10th
KimCare, 1-800-789-4495
13th
KimCare
10th
Wound Care Direct.com, www.WoundCareDirect.com Krames Communication
10th 11th
KimCare
10th
John D. Dingell VA Medical Center, Detroit, Mich John D. Dingell VA Medical Center, Detroit, Mich
9th
8th 8th
*SMOG short version.
2. Are the characteristics of organization, writing style, appearance, and appeal of these materials, measured by the AHEC checklist, appropriate for patients with low literacy skills?
METHODS Research Design The study used a nonexperimental, descriptive design to examine the readability and appropriateness of patient education materials focused on skin care and pressure ulcers.
properties for the AHEC checklist are not yet available. The SMOG12 is a manually computed readability formula commonly used in health care. There are 2 versions of this formula: a regular version for evaluating written materials that contain 30 or more sentences and a short version for evaluating materials that contain less than 30 sentences. The SMOG was selected because it is accurate and correlates highly with other readability formulas (FOG, r = 0.99, and Fry, r = 0.93).7,13
Procedure Setting and Education Materials Ten patient education materials were evaluated (see the Table). These educational materials were commonly used in acute care hospitals, home care, and public clinics in an urban environment in the Midwest.
Instruments Two instruments were used in this study: the SMOG16 and the AHEC checklist.24 The AHEC checklist assessed organization, writing style, appearance, and appeal of the materials. Any item in the checklist that was not addressed in the material indicated that the materials were likely to be inappropriate for low-literacy patients. To obtain inter-rater reliability, 2 evaluators independently assessed the appropriateness of each of the 10 educational materials and reached a 90% agreement in the evaluation. In essence, 9 out of 10 times, the raters agreed on the evaluation. Psychometric
A convenience sample of written patient education materials (N = 10) were evaluated for their readability. These materials were selected because nurses in an urban ambulatory clinic commonly used them as primarily teaching tools. The AHEC checklist was used to evaluate the characteristics of organization, writing style, appeal, and appearance and the SMOG.
RESULTS Readability Results of Patient Education Materials The overall readability for the patient education materials on skin and pressure ulcers was 10th grade (SD = 1.71). The scores ranged from a low of 7th grade for information in the pamphlet titled “Diabetes Foot Care” to a high of 13th grade for the brochure “Caregiving: Compression, Loving, Coping.” Five of the materials were higher than the 8th-grade level and 5 were at or below the recom-
The study used a nonexperimental, descriptive design to examine the readability and appropriateness of patient education materials focused on skin care and pressure ulcers.
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Box 2 Developing easy-to-read written patient education materials Do: 1. Match education materials with the characteristics of the target reader (ie, age, gender, ethnicity). 2. Use a minimum number of medical terms and jargon. 3. Use drawings or pictures that are appropriate and convey the message. 4. Make sure the material is written at the appropriate reading level of the anticipated reader. 5. Check the readability of the material for reader appropriateness. 6. Make materials simple, concise, and easy to follow. 7. At the beginning phase, seek input from people for whom the information is targeted. Don’t:
Although experts suggest that readability at the 8th grade level and below is acceptable for the general public,9,10 that level may still be too high for many patients who are poorly educated, elderly, and reside in urban areas.
1. Write materials using the passive voice. 2. Crowd the page with lots of words and pictures. 3. Develop one-size-fits-all written patient education materials.
mended level, placing them at an appropriate reading level for many patients to understand the information (see the Table).
Results of the AHEC Checklist Evaluation Organization. The majority of the pamphlets and brochures presented the “need to know” information either at the middle or at the end. Eighty percent of the documents were commercially developed with attractive, colorful covers. A majority of the materials used headers to guide the reader but seldom summarized the information or emphasized the expected health behavior of the reader. Writing style. The writing style of the materials consisted mostly of passive voice rather than the recommended conversation of active voice. Some of the words in the pamphlets such as “seborrheic keratosis” or “actinic keratosis” made the materials difficult to read; however, the majority of the materials used simple words and minimal medical terminology. Appearance. The print size of the materials ranged from a low of 11 points to a high of 14 points. Some of the illustrations were simple and clearly conveyed the message; other illustrations were extremely complex with difficult anatomic drawings of the layers of the skin, circulation system, and nervous system. Appeal. Although the materials were used in diverse populations, none addressed cultural needs of the patients. One brochure displayed a picture of a person of color on the cover, but the information contained within the text was generic. In fact, none of the materials specifically addressed the experiences of caring for pressure ulcers from a cultural perspective.
DISCUSSION This study examined the readability and design characteristics of skin and pressure ulcer patient
education materials. One limitation of this study is the small sample size, which limits the generalizability of the results to the materials in this study. Even though half the materials had acceptable readability levels, none of the brochures met both the readability level and each attribute criterion of AHEC, making them inappropriate as teaching tools for low-literacy patients. Although experts suggest that readability at the 8th-grade level and below is acceptable for the general public,9,10 that level may still be too high for many patients who are poorly educated, elderly, and reside in urban areas. For these patients, Doak and colleagues7 recommended between a 3rd- and 5th-grade readability level. The lack of available easy-to-read health information and education materials for disadvantaged patients increases barriers to care and prevents consumers from making informed choices. When a limited amount of patient education materials is available or the available materials are inappropriate, the WOC nurse can develop pamphlets and brochures to meet the needs of a target audience. Desktop publishing, clip art, and computer programs are helpful in this endeavor. Computer programs contained in Microsoft Word for Windows18 such as “Art Clip” and “Word Art” are tools that can be used to develop materials economically and yield a product that is appealing, well organized, and appropriate. A starting point would be to determine learning objectives for the intended reader. Next, a brief outline of the information to be included in the materials should be written. The “need to know” information or expected patient behavior must be placed at the beginning of the materials. For example, a pamphlet about keeping the skin clean would begin with a section on “Steps to Keeping the Skin Clean—Step 1.” The materials must be written simply and clearly. Well-placed illustrations or simple drawings that depict the steps of keeping skin clean will
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KEY POINTS • One in 5 Americans reads at the 5th-grade level or below. • Some written education materials require literacy skills 2 to 3 grades higher than the patient’s reading level. • WOC nurses must understand how to choose or develop written materials that are congruent with the reading skills of their patients.
help the reader. Sentences should be short, contain limited medical terms, and be written in conversational style or active voice rather than passive voice. For example, “Patients are advised to keep skin clean and lubricated” is in the passive voice, whereas “Keep your skin clean and lubricated” is written in the conversational voice. Short sentences in the conversational voice enhance comprehension. It is recommended that only 3 to 4 main points be on a page and that paragraphs preferably be presented in bullet formation. The writer should refrain from using all UPPERCASE letters, because this practice makes it difficult for the reader to follow the text.17 Some of the key points for developing easy-to-read materials are presented in Box 2. Several publications in the literature can guide the WOC nurse in selecting and/or developing easy-to-read materials.7,24-28 These materials should be tested with potential readers early in the developmental phase to determine if the information is comprehendible. Osborne29 recommended testing materials using focus groups or simply getting feedback from 10 to 20 patients before use. WOC nurses must understand how to choose written materials that are congruent with the reading skills of their patients. During the initial nursing assessment, a measure that evaluates reading comprehension can be given to the patient. Because of the shame and embarrassment associated with low literacy, it is unlikely that patients will volunteer this information. One reading test widely used in health care is the Rapid Estimate of Adult Literacy in Medicine.30 This test is a userfriendly word recognition test than can be administered in a clinical setting, is not intimidating for the WOC nurse, and usually can be completed in 10 minutes. WOC nurses are encouraged to be sensitive during the interview and make the patient as comfortable as possible. Written information should complement verbal teaching and should not be a replacement for faceto-face patient education. While the discussion of health care delivery for this vulnerable populations grows, WOC nurses are encouraged to take an active leadership role in developing educational strategies that meet the needs of patients who cannot read and have pressure ulcers. Some of the ways in which nurses can have an active role
is to (1) write letters to the publisher of patient education materials regarding their strengths and weaknesses, (2) participate on committees that develop or choose materials used by the health organization, and (3) participate in the field testing of these materials. REFERENCES 1. Pieper B, Templin T, Dobal M. Wound prevalence, type, and treatment in home care. Adv Wound Care 1999;12:117-26. 2. Wilson FL. Are patient information materials too difficult to read? Home Healthcare Nurs 2000;18:10715. 3. Xakellis G. Cost of pressure ulcer prevention in longterm care. Adv Wound Care 1998;1:22-9. 4. Kirsch IS, Jungleblut A, Jenkins L, Kolstead A. Adult literacy in America: national adult literacy survey. Washington: National Center for Education Statistics, US Department of Education; 1993. 5. Weiss B, Hart G, Pust R. The relationship between literacy and health. J Health Care Poor Underserved 1993;1:351-61. 6. Wilson FL, Baker L, Syed-Brown C, Gollop C. Readability of cancer patient education information found on CancerNet. Oncol Nurs Forum 2000;27: 1403-9. 7. Daok LC, Doak CC, Root J. Teaching patients with low-literacy skills. Philadelphia: Lippincott; 1996: p. 3-15, 40-57. 8. Redman B. The practice of patient education. 8th ed. St. Louis: Mosby; 2001: p. 50-67. 9. Estey A, Musseau A, Keehn L. Patient’s understanding of health information: a multihospital comparison. Patient Educ Couns 1994;1:73-8. 10. Streiff L. Can clients understand instruction? J Nurs Scholarsh 1986;18:48-52. 11. Pfizer Health Literacy Initiative. “Health Literacy: Leading Edge Practices.” September 18-19, 2002; Washington, DC. 12. Contreras A, Garcia-Alonso R, Echenique M, DaveContreras F. The SOL formulas for converting SMOG readability scores between health education materials in Spanish, English, and French. J Health Commun 1999;4:21-9. 13. Meade C, Smith C. Readability formulas: caution and criteria. Patient Educ Couns 1991;17:153-8. 14. Fry E.Fry readability graph: clarification,validity,and extension to level 17. J Reading 1977;21:242-52. 15. Flesch R.A new readability yardstick. J Appl Psychol 1948;32:221-3. 16. McLaughlin HG. SMOG: Grade a new readability formula. J Reading 1969;12:641-6.
Written information should complement verbal teaching and should not be a replacement for face-toface patient education.
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17. Klare G. Readability. In: Person PD, editor. Handbook of reading research. New York: Longman; 1984: p. 681-774. 18. Microsoft Corporation. A guide for Microsoft Word for Windows 2000. Redmond (WA): Microsoft Corporation; 2000. 19. Ley P, Florio T. The use of readability formulas in health care. Psychol Health Med 1996;1:7-28. 20. Ayello E. A critique of the AHCPR’s “preventing pressure ulcers—a patient’s guide” as a written instructional tools. Decubitus 1993;6:44-50. 21. Falvo D. Effective patient education: a guide to increase compliance. Rockville (MD): Aspen; 1985. 22. Gunning R. The FOG index after twenty years. J Bus Commun 1968;6:3-13. 23. Ayello E. Critique of AHCPR’s consumer guide “Treating pressure sores.” Adv Wound Care 1995; 8:19-32. 24. Plimpton S, Root J. Materials and strategies that work in low literacy health communication. Public Health Rep 1994; 109:866-91.
25. Wilson FL. The suitability of United States pharmacopoeia dispensary drug leaflets for urban psychotropic patients with limited reading skills. Arch Psychiatr Nurs 1999;13:204-11. 26. Horner SD, Surratt D, Juliusson S. Improving readability of patient education materials. J Community Health Nurs 2000;17:15-23. 27. Walsh D, Shaw D. The design of written information for cardiac patients: a review of the literature. J Clin Nurs 2000;9:658-67. 28. Wilson FL. Evaluation of education materials using Orem’s self-care deficit theory. Nurs Sci Q 2003; 16:68-76. 29. Osborne H. In other words…can they understand? Testing patient education materials with intended readers [online]. Available from: URL: http://www. healthliteracy.com/oncallnov2001.html 30. Murphy P, Davis T, Long S, Jackson R, Jackson B. Rapid estimate of adult literacy in medicine. J Reading 1993;37:123-30.
Publisher’s Award for Original Research The Publisher’s Manuscript Award for Original Research is awarded to the author(s) of a manuscript that makes a significant contribution to WOC nursing. This award is designed to recognize excellence in the field. Manuscripts will be judged for their scholarship, originality, and relevance to WOC nursing. All manuscripts that are published within a volume (calendar year) and meet the eligibility requirements are evaluated for the award, which is presented at the WOCN Annual Conference the following spring. In the event an insufficient number of manuscripts are published within a volume, those published manuscripts will be held for consideration for the award the following year. The award is composed of an honorarium in the amount of $500 and a plaque. The check is issued in the name of the corresponding author, and the plaque includes the names of all authors. The eligibility requirements are as follows: Research report must be original and not published or submitted for publication elsewhere. Manuscript must be 2000 words or more. It is not necessary to be a member of the WOCN or have graduated from a WOCN Educational Program or an ET Nursing Education Program to compete for the award. The manuscript cannot be authored by any member of the Editorial Board. All eligible manuscripts are evaluated by the Journal’s Editorial Board.
This award is funded by the Journal of WOCN and Mosby, Inc.