Incorporating Health Literacy Design
in Patient Education: A Brief Case for
the Efficacy of Education and How to
Effectively Evaluate Education
Agenda
• Brief review on the Research
• Evaluating Patient Education Content –
SAM
• Format/Delivery Options
• Discussion
Patient Education Rationale
• Demonstrated impact on key outcomes
• Cost containment strategy
• Regulatory pressure – NCQA, Joint
Commission
• Healthcare Consumerism
– Members Demand it
– Competition
– Patient Satisfaction Scoring
• Literacy demographics
• Patient Safety
Patient Education Rationale
Model of Patient Education Outcomes
Knowledge and
Health Status
Attitude Changes Physical health
Increased understanding
Well-being
Increased confidence Symptoms
Patient Increased satisfaction
Education Complications
Improved emotional state
Print
Verbal
Multimedia
Combination
Costs
Behavior Changes Length of stay
Health services utilization Utilization
Compliance Litigation
Lifestyle Provider image
Self-care Regulatory
compliance
Patient Education Rationale
Other Benefits
• Enhance quality brand
• Support IT Investments
• Patient Satisfaction
• Compliance with accreditation
standards
• ROI – The Holy Grail or the
Impossible Dream
Patient Education Outcomes
Studies Rarely Compare Elements or Types
of Educational Materials
• Black-and-white versus color
• Booklet versus brochure
• Text versus text with illustrations
• Media comparisons — telephone,
print, computer, video
Patient Education Outcomes
Text versus Text with Illustrations
• 101 patients discharged from ER with
lacerations
• Written follow-up care with or without graphics
• Significant comprehension improvement
overall; greater improvement with illustrations
• Illustrations improved comprehension an
average of 50% in general and 100% in
nonwhites
Patient Education Outcomes
Increased Knowledge
Vickers, Kristin S. Vickers PhD., et al. Randomized Controlled Trail
Assessing the Impact of “Living Well with Heart Failure” Toolkit on Patient
Attitude and Health Behaviors. Presented 2009 American Academy of
Health Behavior Annual Conference.
• Selected HF Patients at Mayo Clinic mailed workbook with
letter.
• 81% increased knowledge
• 72% increased confidence
• 61% reported behavior change
• Education sent via mail represents a minimal, cost-
limited intervention that provides a behavioral prompt
for ongoing disease self-management
Patient Education Research
Increased satisfaction
Lo, Struenkel, Rodiguez, The Impact of Diagnosis-Specific Discharge
Instructions on Patient Satisfaction Journal of PeriAnesthesia Nursing Vol
24, No 3 (June) 2009; pp 156-162.).
• Literature review indicated clear education would
improve patient/provider communication resulting in
improved patient satisfaction scores.
• Pre-/post- Krames On-Demand Implementation
study conducted in Endoscopy Unit, Main Surgery
Unit, and Ambulatory Unit
Diagnosis specific Discharge Instructions
improve Patient Satisfaction scores for eight of
nine measures.
Patient Education Research
Increased satisfaction
George CF, Waters WE & Nicholas JA (1983). Prescription information
leaflets: A pilot study in general practice. Brit med J, 287,1193–96.
•Recipients of information were more likely to be completely satisfied with
treatment and with information given to them.
•Recipients of information were more likely to know the name of their
medications and potential side effects.
•Informed patients were no different in reporting side effects.
•68% of the leaflet group were completely satisfied with their treatment
compared to only 55% of the non-leaflet group.
Findings dispel concern that information will lead to complaints.
Patient Education Research
Increased satisfaction
Gibbs S, Waters WE, & George CF (1990). Communicating information to
patients about medicine. The Royal Society of Medicine.
• Brochure recipients knew more about their
medications and side effects,and were more satisfied
than nonrecipients.
• Patients of both sexes; all age groups, and all social
classes benefited from the leaflets.
Information can have an impact on a diverse
audience.
Patient Education Research
Improved Affect
Laine L, Shuman RJ, Bartholomew K, Gardner P, Reed T, & Cole S
(1989). An educational booklet diminishes anxiety in parents whose
children receive total perinatal nutrition. Am J Diseases in Children.
143, 374–77.
• No-booklet patients experienced less comfort in caring for their
children and less knowledge about nutritional treatment.
• Written information decreased anxiety and increased
satisfaction with patient care more successfully than verbal
communication.
• Booklet group was 22% more comfortable with the treatment
and 10% less anxious.
Information can have an important impact on mental
health.
Patient Education Research
Health Behavior Change
Roland M, & Dixon M (1989). Randomized controlled trial of an
educational booklet for patients presenting with back pain in General
practice. J Royal Col of Gen Practitioners, 39, 244–46.
• Booklet group showed reduced office visits for back pain,
physical therapy referral, hospital admissions, laminectomies.
• One year later, 94% said they read the booklet, 84% found it
useful, 68% still had a copy.
• Knowledge test scores significantly higher in booklet group.
• 15% fewer office visits in the experimental group.
Cost-effective program for common, expensive problem.
Patient Education Research
Health Behavior Change
Taylor, et al. Effectiveness of an Educational Intervention in Modifying
Parental Attitudes about Antibiotic Usage in Children. Pediatrics. May
2003 v 111 i5 p 1099.
• Simple patient education intervention about to improve
attitudes concerning use of antibiotics.
• Focus on Childhood conditions.
Educated parents modified attitude and understood
the value in judicious use of antibiotics after receiving
patient education intervention
Patient Education Research
Health Behavior Change
Frederikson LG, & Bull PE (1995). Evaluation of patient education
leaflet designed to improve communication in medical consultations.
Patient Ed and Counseling, 25, 51–57.
• Materials on patient-doctor communication.
• Patients reading the leaflets increased knowledge and
improved communication skills.
• Doctors rated 57% of control patient interactions good versus
80% of experimental group.
• 15% fewer office visits in the experimental group.
Educated patients have more positive doctor-patient
interaction.
Patient Education Research
Improved Health Status
Wallace LM, (1986). Communication variables in the design of
pre-surgical preparatory information. Brit J Clin Psych, 25, 111–18.
• Experimental group had greater knowledge and fewer
worries about surgery.
• Placebo group had more misconceptions than
experimental or control groups did.
• Analyses showed that patients who have more knowledge
about surgery have fewer worries and recover faster.
Patients who had more knowledge also recovered
faster.
Patient Education Outcomes
Health Behavior Change
Serxner S, et al (1998). Congestive Heart Failure Disease Management
Study: A Patient Education Intervention. CHF, May/June 23–28.
• Intervention: series of four mailings
– 3 weeks postdischarge: knowledge of self-
management
– 6 weeks: meal planning, shopping & cooking skills
– 9 weeks: making lifestyle change & depression
– 12 weeks: CHF video plus brochures on wellness,
stress, and medication use
• Extremely positive ROI
– 51% reduction in readmissions
– Hospital savings = $8/$1
– Health plan savings = $19/$1
Patient Education Outcomes
Better Prepared Patients & Reduced Costs
Abuksis G., et al, A Patient Education Program is cost-effective for preventing
failure of endoscopic procedures in gastroenterology department. American
Journal of Gastroenterology. Volume 96 Issue 6 page 1786 – June 2006.
• 3 Groups:
– A. Received brochure and individual session with nurse
– B. Received brochure only
– C. Received brochure and phone call
• Results
– Group A – 4.39% cancellations, 8.6% lower costs
– Group B – 26.31% cancellations, 8.9% lower costs
– Group C – 15.38% cancellations, 5.5% lower costs
• Conclusions: Pre-endoscopy education improved compliance
resulting in:
– Reduced Need for Repeat Examination and their attendant
costs
Patient Education Outcomes
Patient Education Reduces Costs
Jack, Brian W, MD., et al, A Reengineered Hospital Discharge Program to
Decrease Rehospitalization, A Randomized Trial. Annals of Internal Medicine.
Volume 150 Issue 3 pages 178-187, Feb 2009.
• Test group in ER received counseling on how to take
medications along with patient education on diagonsis.
• Test group was 30 percent less likely to be readmitted or
visit the emergency department than patients who lack
this information
• Total costs (a combination of actual hospitalization
costs and estimated outpatient costs) were an
average of $412 lower for the patients who received
complete information than for those who did not.
Patient Education Research
Consistently Reported Benefits
• Increased satisfaction
• Improved comprehension and recall
• Relieved stress and anxiety
• Behavioral impacts on drug and treatment,
compliance, and self-care
Evaluating Education Materials
Importance of Health Literacy
• IOM Report – Health Literacy: A Prescription to
End Confusion
– 90 Million Americans have trouble understanding
health Information
– 50% US Adults
• Joint Commission Report – 2007 – “What Did
the Doctor Say?” Improving Health Literacy to
Protect Patient Safety
– Low Health Literacy/Miscommunication increases risk
for preventable adverse events.
Evaluating Education Materials
• It’s more than Reading Level
• Critical elements to consider
– Attraction
– Comprehension
• Short Term Memory only recalls 7 items
• Memory favors visuals
– Self-Efficacy
– Cultural Acceptability
– Persuasion
• Motivating Behavior Change
Evaluation of Education Materials
Suitability Assessment of Material (SAM)
by Doak, Doak, & Root
• Content
• Literacy Demand
• Graphics
• Layout and typography
• Stimulus to learn/motivation
• Cultural appropriateness
Evaluation of Education Materials
Content
• Purpose evident
• Content on behaviors
• Scope limited
• Summary/review
Evaluation of Education Materials
Purpose is evident
and scope is limited.
Evaluation of Education Materials
Literacy Demand
• Reading level
• Active voice
• Common words
• Context placement
• Learning aids/sign
Evaluation of Education Materials
Active voice and
common words are
used for ease of
comprehension.
Evaluation of Patient Materials
Graphics
• Cover shows purpose (booklets)
• Style of graphics
• Visuals carry content
• Captions match visual content
Evaluation of Education Materials
Cover shows purpose.
Evaluation of Education Materials
Medical art is simplified to tell a story.
Evaluation of Education Materials
Layout and Typography
• Page design
• Type styles
• Content chunking
Evaluation of Education Materials
Information is
broken into
easy-to-read chunks.
Visuals carry content.
Evaluation of Education Materials
Type size is
appropriate for
audience.
Evaluation of Education Materials
Stimulus to learn/Motivation
• Interactive
• Behaviors modeled
• Specific and relevant behaviors
• Self-efficacy
Evaluation of Education Materials
Specific and relevant
behaviors are
modeled.
Increase Self-Efficacy
Evaluation of Education Materials
Interactive
elements
involve the
reader.
Evaluation of Education Materials
Cultural Appropriateness
• Logic, language, and experience match
• Cultural images
• Cultural examples
Evaluation of Education Materials
Images reflect
targeted
cultures and
match
experience
Summary
• Patient Education has positive impact
on health and behavioral outcomes
• Literacy is key to educational
effectiveness
• Materials need to be suited to the
audience
• Evaluation on “ suitability ” not
reading–level
Evaluating Modalities/Delivery
• Print
– Booklets
– Brochures
– Tear Sheets
– Posters
• Audio
• Video
• Online and What does that mean
– Understand – it is expected – how we communicate
today
You Probably Need a Mix.
Electronic Solutions
• Embrace an Universal Solution
– Case Manager Access/Distribution tools
• Print On-Demand
• Video
• Information Therapy
– Online
– Offline
– Member Direct Access
• Websites/Portals
• PHRs
• E-Mail pre/post clinical intervention
– After Visit Summary with Providers
– Pre-op/post-op
Summary
• Research supports the efficacy and
importance of patient education. It
works.
• When evaluating content – go beyond
reading-level and consider Suitability
Assessment of Materials (SAM).
• When choosing delivery formats
remember
– Corporate Strategic Objectives
– Expectations of Members
– Need to tie into Electronic Systems
Electronic Solutions
• Bring in IT early
• Achieve a basic understanding of your IT 3-5 year plan.
– Systems/Upgrade Plans
– IT Philosophy – Best of Class v. Single Source
• How Does Patient Education fits in to IT plan
– Stand-alone or integrated
• Integration – Interoperable or Baked In
– Documentation requirements
– Purse-Strings
Selling Your Solution Internally
• Positioning Solution to fit in with
strategic plan.
• Create the business case for your
solution.
– ROI Calculators
– Tailored Presentations
– Proper Utilization/Patient Driven/Patient
Satisfaction/Outcomes considerations
• Leverage Your Vendors as much as
possible.
Delivering Patient Education
• Checklist
– Do solutions meet patient care objectives?
– Do solutions meet facility’s strategic
imperatives? Do I have buy in?
– Do solutions meet patient
expectations/demands?
– Do we have an 360 degree solution?
– The world is moving to e-solutions, are we?
– Do solutions align with corporate goals?
– Have I made a compelling case for my
solutions?