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Incorporating Health Literacy Design in Patient Education Materials: 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.

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Incorporating Health Literacy Design in Patient Education Materials: A Brief Case for the Efficacy of Education and How to Effectively Evaluate Education

  • Brief review on the Research
  • Evaluating Patient Education Content – SAM
  • Format/Delivery Options
  • Discussion
patient education rationale
Patient Education Rationale
  • Demonstrated impact on key outcomes
  • Cost containment strategy
  • Regulatory pressure – Joint Commission, NCQA ARRA – Meaningful Use – Included criteria for patient education (June 16, 2009).
  • Healthcare Consumerism
    • Patients Demand it
    • Competition
    • Patient Satisfaction Scoring
  • Literacy demographics
  • Patient Safety

Patient Education Rationale

  • Health Status
  • Physical health
  • Well-being
  • Symptoms
  • Complications
  • Patient
  • Education
  • Print
  • Verbal
  • Multimedia
  • Combination
  • Costs
  • Length of stay
  • Utilization
  • Litigation
  • Provider image
  • Regulatory compliance
  • Behavior Changes
  • Health services utilization
  • Compliance
  • Lifestyle
  • Self-care

Model of Patient Education Outcomes

Knowledge and Attitude Changes

  • Increased understanding
  • Increased confidence
  • Increased satisfaction
  • Improved emotional state
patient education rationale1
Patient Education Rationale

Other Benefits

  • Enhance quality brand
  • Support IT Investments
  • Patient Satisfaction
  • ROI – The Holy Grail or the Impossible Dream
patient education outcomes
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 outcomes1
Patient EducationOutcomes

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
Patient EducationResearch

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 research1
PatientEducation Research

Increases 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

  • 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

  • Satisfaction & Communication
  • 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 outcomes2
Patient Education Outcomes

Health Behavior Change

  • 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

Serxner S, et al (1998). Congestive Heart Failure Disease Management Study: A Patient Education Intervention. CHF, May/June 23–28.

patient education outcomes3
Patient Education Outcomes

Better Prepared Patients & Reduced Costs

  • 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

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.

patient education outcomes4
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 diagnosis.
  • 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 outcomes5
Patient Education Outcomes

Asthma Education Intervention Reduces ED Visits

  • Education interventions for monitoring breathing flow, early response to symptoms, caregivers making environmental changes at home.
  • Reviewed 38 studies involving 7,843 children.
  • Compared to control groups, those receiving education interventions significantly reduced risk of subsequent ER visits and hospitalizations.

Literature Review - Cochrane Airways Group Trail Registry, The Cochrane Library, June 2009.


Health Education Research

  • Consistently Reported Benefits
  • Increased satisfaction and health status
  • Improved comprehension and recall
  • Behavioral impacts on drug and treatment, compliance, and self-care
  • Reduced Costs
evaluating patient education materials
Evaluating Patient 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.
  • Low Health Literacy: Implications for National Health Policy. Vernon et al – 2007
    • Annual health care costs due to miscommunication rooted in health literacy issue - $106 – 238 Billion.
evaluating patient education materials1
Evaluating Patient 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 patient education materials
Evaluation of Patient 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 patient education materials1
Evaluation of Patient Education Materials


  • Purpose evident
  • Content on behaviors
  • Scope limited
  • Summary/review
purpose is evident and scope is limited
Purpose is evident and scope is limited.

Evaluation of Patient Education Materials

evaluation of patient education materials2
Evaluation of Patient Education Materials

Literacy Demand

  • Reading level
  • Active voice
  • Common words
  • Context placement
  • Learning aids/sign
active voice and common words are used for ease of comprehension
Active voice and common words are used for ease of comprehension.

Evaluation of Patient Education Materials

evaluation of patient materials
Evaluation of Patient Materials


  • Cover shows purpose (booklets)
  • Style of graphics
  • Visuals carry content
  • Captions match visual content
cover shows purpose
Cover shows purpose.

Evaluation of Patient Education Materials

medical art is simplified to tell a story
Medical art is simplified to tell a story.

Evaluation of Patient Education Materials

evaluation of patient education materials3
Evaluation of Patient Education Materials

Layout and Typography

  • Page design
  • Type styles
  • Content chunking
information is broken into easy to read chunks visuals carry content
Information is broken into easy-to-read chunks.Visuals carry content.

Evaluation of Patient Education Materials

type size is appropriate for audience
Type size is appropriate for audience.

Evaluation of Patient Education Materials

Asthma and Your Child: Helping Your Child Stay Active and Healthy

All About Asthma: What I Can Do to Feel Good

evaluation of patient education materials4
Evaluation of Patient Education Materials

Stimulus to learn/Motivation

  • Self-efficacy
  • Behaviors modeled
  • Specific and relevant behaviors
  • Interactive
specific and relevant behaviors are modeled increase self efficacy
Specific and relevant behaviors are modeled.Increase Self-Efficacy

Evaluation of Patient Education Materials

interactive elements involve the reader
Interactive elements involve the reader.

Evaluation of Patient Education Materials

evaluation of patient education materials5
Evaluation of Patient Education Materials
  • Logic, language, and experience match
  • Cultural images
  • Cultural examples

Cultural Appropriateness

evaluating patient education summary
Evaluating Patient Education Summary
  • Literacy is key to educational effectiveness
  • Materials need to be suited to the audience
  • Evaluation on “suitability”not reading–level
evaluating modalities delivery
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
Electronic Solutions

Embrace an Universal Solution

  • Case Manager Access/Distribution tools
    • Print On-Demand
    • Video
    • Information Therapy
      • Online
      • Offline
  • Patient Direct Access
    • Websites/Portals
    • PHRs
    • E-Mail pre/post clinical intervention
      • After Visit Summary with Providers
      • Pre-op/post-op
electronic solutions1
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
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 Satisfaction /Outcomes considerations
  • Leverage Your Vendors as much as possible.
delivering patient education
Delivering Patient Education


  • Do solutions meet patient care objectives?
  • Do solutions meet organization’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?
  • 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 Patients
    • Need to tie into Electronic Systems
  • ROI Calculators –
  • SAM Scale – Teaching Patients with Low Health Literacy Skills, Doak,Doak, and Root. Free Download at Harvard School of Public Health website -
Thank You,

Bob Abrahamson

Vice President, Marketing

Krames StayWell