Nursing Science Quarterly - CiteSeerX

Nursing Science Quarterly http://nsq.sagepub.com

Evaluation of Education Materials Using Orem’s Self-Care Deficit Theory Feleta L. Wilson, Darlene W. Mood, Joanna Risk and Trace Kershaw Nurs Sci Q 2003; 16; 68 DOI: 10.1177/0894318402239069 The online version of this article can be found at: http://nsq.sagepub.com/cgi/content/abstract/16/1/68

Published by: http://www.sagepublications.com

Additional services and information for Nursing Science Quarterly can be found at: Email Alerts: http://nsq.sagepub.com/cgi/alerts Subscriptions: http://nsq.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav

Downloaded from http://nsq.sagepub.com at PENNSYLVANIA STATE UNIV on April 10, 2008 © 2003 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

10.1177/0894318402239069 Evaluation Nursing Science of Education Quarterly, Materials 16:1, January 2003

ARTICLE

Evaluation of Education Materials Using Orem’s Self-Care Deficit Theory Feleta L. Wilson, RN; PhD Associate Professor, College of Nursing, Wayne State University, Detroit, Michigan

Darlene W. Mood, PhD Professor, College of Nursing, Wayne State University, Detroit, Michigan

Joanna Risk, RN; MPH Project Director, College of Nursing, Wayne State University, Detroit, Michigan

Trace Kershaw, PhD Postdoctoral Fellow, Yale University, New Haven, Connecticut This article presents Orem’s self-care deficit nursing theory as the conceptual framework in the development, design, selection, and evaluation of appropriate written patient education materials for patients with low literacy skills. The model, which includes essential evaluation factors used in literacy research, offers nurses and other professionals a more comprehensive means to judge the suitability of health information and instructional materials. Nurses have a critical role in educating consumers and their families and for providing patients with useful information that will influence their decision-making and participation in care.

A

growing body of knowledge on patient education and patient literacy is cited in the literature. The scientific development of this area of research sets forth a need to develop theory-based evaluation models as frameworks specific to the assessment of appropriate patient education materials. The writings of Riley (1963) emphasize that conceptual models are organizing images of a phenomenon that determine what questions are to be addressed in research and how research tools are to be used to find answers. Thus, the development of a theoretically sound model that is empirically tested is a needed next step in the area of health literacy. This Authors’ Note: This study was financially supported by a Supplement for Underrepresented Minority Investigator Award from the National Cancer Institute (Grant No. R01 CA59013-11S1) and Lambda Chapter, Sigma Theta Tau International. Nursing Science Quarterly, Vol. 16 No. 1, January 2003, 68-76 DOI: 10.1177/0894318402239069 © 2003 Sage Publications

article exemplifies the process of theoretical model construction followed by an empirical test of the model. Written materials are by far the most frequently used tools for educating patients despite evidence suggesting they are inappropriate for a significant number of consumers who cannot read or comprehend the information (Doak, Doak, & Root, 1996; Redman, 1997). The lack of available easy-to-read health information and instruction materials for patients with poor literacy skills heightens health disparities and dissatisfaction with care already experienced by many disadvantaged patients. Written education materials are used daily in public and private clinics, physician and advanced practitioner offices, hospitals, and community-based health centers without an adequate evaluation of their suitability for patients. Effective communication of health information is pivotal to the efforts of practitioners in promoting health, changing behaviors and attitudes, and preventing disease (Airhihenbuwa &

Obregon, 2000). The techniques used to communicate with low-literacy patients will influence their decisions to participate in their own care; they may view the unreadable material as another barrier to healthcare. For that reason, the evaluation of patient education materials should be viewed as a measure of accountability and quality care. If healthcare providers are responsible for teaching and communicating with patients using the written media, a model that guides the process for evaluating these materials is warranted. The overall purpose of this study was to test a model for evaluating written patient education materials. Included in the article is a description of the model, pilot testing of the model, a discussion of study results, and implications. For illustrative purposes, Radiation Side Effect Information (RSEI) cards (Mood & Bickes, 1992) that provided self-care information and instructions Keywords: literacy, Orem’s selfcare deficit theory, patient education


Evaluation of Education Materials on management of radiotherapy side effects were used as examples to demonstrate the model because they were judged to be typical of many written patient education tools. The RSEI cards were pretested in several earlier clinical trials with outcomes of positive patient satisfaction (Mood & Bickes, 1992; Mood, Horowitz, & Chadwell, 1987). A more in-depth description of the cards will be presented later in the article. Health and Patient Literacy For many decades, educators have focused on the plight of poor readers and related societal problems such as school drop-out, unemployment, and inability to be competitive in the job market. It was only in the 1970s and 80s that researchers began to investigate problems of patient low literacy and healthcare. These exploratory studies reported that approximately 20% of adults were illiterate and another 34% were marginally competent readers (Doak & Doak, 1980; Roth, 1976; Streiff, 1986). Doak et al. (1996) later found that 50% of the patients had poor reading skills, and they were usually poorly educated, minorities, elderly, and of low income status. The landmark National Adult Literacy Survey (NALS) made the national literacy problem clearer (Kirsch, Jungleblut, Jenkins, & Kolstad, 1993). The authors reported that approximately 40% of adults in the United States are poor readers. The survey also disclosed that while 25% of adults in the United States had an average of a 10thgrade education, they read on an average of a 4th-grade level or lower. The NALS study found a relationship between income and literacy, with higher literacy levels found among those with higher incomes. Study participants at level one, the lowest level of literacy, had weekly incomes around $240, while those at level five earned about $680 weekly (Wagner & Venezky, 1999). Weiss, Hart, McGee, and D’Estelle (1992) discussed the health indices for

poor readers. Low-literacy patients were reported to have higher morbidity and mortality than the general population (Plimpton & Root, 1994), were less likely to comply with recommended treatments and health maintenance (Hartmann, Draeger, & Berrnstein, 1991), and were more likely to misuse medications (Hussey & Gilliland, 1989). Given the serious nature of these circumstances, the area of patient education needs further exploration to specifically address the needs of lowliteracy patients and the strategies used to teach them. Evaluating Written Patient Education Materials Over the years, researchers have developed techniques to review and evaluate written patient education materials. In healthcare, one of the major techniques used to examine written materials is readability formulas. These formulas are standardized measures that mathematically analyze the number of words, sentences, and affixes to determine the reading demands of materials (Contreras, Garcia-Alonso, Echenique, & Daye-Contreras, 1999). The formulas widely used to predict readability levels include Fry (1977), Flesch (1948), SMOG (McLaughlin, 1969) and the Gunning-Fog (Gunning, 1968). Evaluation, however, goes beyond the assessment of readability. Bernier and Yasko (1991) added another dimension to assessing materials by creating a model to design and evaluate materials that parallels the nursing process of assessment, planning, implementation, and evaluation. This evaluation model consists of five phases: (a) predesign, (b) design, (c) pilot testing, (d) implementation, and (e) evaluation. Rice and Valdivia (1991) developed a Likert scale to assess patient education materials. Their scale is based on specific operating principles. These principles include developing materials from a community perspective, ensuring that the materials are part of an education program, relating the materials to health

69

services being delivered, and pretesting the materials. Other studies have used checklists to examine the various characteristics of written materials. Plimpton and Root (1994) used this method to analyze vocabulary, sentence length, information overload, tone of the material, and conceptual complexities. Ayello (1993) developed several criteria for evaluating patient education materials while assessing materials on wound care produced by the Agency for Health Care Research and Quality, formerly the Agency for Health Care and Policy Research (AHCPR). These criteria stress that material should have expressed objectives, the content should be clear and concise, the materials should include informative visual aids, and the material should be presented in a logical sequence. Although these models have been developed to evaluate materials, they tend to have a weak conceptual foundation and few links with research on learning outcomes. In addition, these models have yet to be scientifically tested. A Model for Evaluating Written Patient Education Materials The model presented here consists of two components: assessment of the patient and his or her environment, and the evaluation of written education materials. There is a dynamic relationship between the two components. A conceptualization of the model is illustrated in Figure 1. Assessment of the Patient and Environment Assessment, the first stage of the model, provides the health professional with pertinent patient information critical to evaluating the patient education materials. To systemically obtain assessment data, three major concepts within Orem’s (1991) self-care deficit theory of nursing guided the process. The three major concepts are self-care agency (SCA) (patient’s ability to en-


70

Nursing Science Quarterly, 16:1, January 2003

Figure 1. A Process Model for Evaluating Written Patient Education Materials NOTE: BCF = basic conditioning factors; SCA = self-care agency; TCSD = therapeutic self-care demand

gage in self-care activities), basic conditioning factors (BCF) (background and health status information), and therapeutic self-care demand (TSCD) (the sum total of activities needed to meet the requirements for self-care). Persons who perform self-care have the ability to do so. Foundational to this ability (SCA) are certain knowing and doing capabilities that include learned skills such as reading, writing, verbal skills, reasoning, perceptual skills, and counting (Orem, 1991). In theory, a limitation in one’s ability to read and comprehend written patient education materials can interfere with one’s ability to judge what should be done in certain situations, or in personal decision-making about self-care or even in performing self-care measures. When one’s ability is less than what is required to engage in self-care, a self-care deficit exists. When a deficit exists and is associated with a limitation to read and comprehend information, for example, the nurse compensates for the deficit either by guiding patients in the selection and use of written patient education materials that are suited to their capabilities, or by employing visual or verbal strategies to educate the patient. Orem (1991) uses the term BCF to signify distinguishing features of individuals and their environment. BCF address those internal or external factors that affect one’s capacity to care for self. They include age, gender, sociocultural orientation, communication modalities, health state, family systems, and socioeconomic status. BCF influence both SCA and TSCD. For exam-

ple, the patient’s age will influence his or her capabilities and what he or she needs to know for self-care. TSCD is the summation of all activities that are necessary to meet one’s known requirements for self-care. Formulating the TSCD requires an investigation and understanding of what selfcare requirements exist and determining what can be done to meet them (Orem, 1971). Therefore, determining the TSCD includes the acquisition and assimilation of information, through written patient education information, needed by a patient experiencing a particular health state change. Thus, the patient assessment data is needed to make judgments about the patient’s self-care capabilities of reading and comprehension abilities, reasoning abilities, perception, and verbal skills as well as the BCF of age, gender, income, health state, and socioeconomic status. These variables are theorized to explain the selection of the provided patient education materials and contribute to an evaluation of their appropriateness for a given patient. For example, do the materials match the patient’s age, gender, and socioeconomic status? Evaluating Written Patient Education Materials The process of evaluating patient education materials is guided by two components: factors congruent with the patient and his or her environment and essential evaluation factors. Factors congruent with the patient and environment refer to elements in the education material that match the findings from

the patient assessment as described in the context of BCF, SCA, and TSCD. The essential evaluation factors are those elements found in the literature that are used to determine whether the material is considered easy-to-read. In evaluating the materials, the evaluator should consider whether the material is congruent with patient factors of age, gender, education, sociocultural orientation, socioeconomic status, learning needs, cognitive abilities, reading and comprehension skills, attitude and beliefs about health practices, knowledge and familiarity about his or her condition, and interest. For example, information obtained from an assessment about the patient’s cultural background, such as his or her communication style and health beliefs, can aid the nurse in determining whether the writing style, content of the information, symbols used to convey the message, and the illustrations used in the education materials are congruent with the patient. Depending on the situation, information on each of these patient variables may not be available; however, more information obtained during the assessment phase increases the potential suitability of the selected written material. The essential evaluation factors, the second component in the model, consist of specific characteristics of the materials: organization, writing style, appearance, and appeal. Organization measures whether the material has an attractive cover, if the need-to-know information is stressed first, that no more than three or four points are presented, if headers and summaries are used, and whether the written summary stresses expected patient behavior. Writing style measures whether the text is written in active or conversational voice, uses minimal amount of medical jargon, and whether the materials are interesting to read. Appearance of the materials evaluates whether there is ample white space, if the pages or sections are uncluttered, if both lower-case and uppercase letters are used, if the typeface is at least 12-point, whether the material uses italicized lettering, and if illustrations are used. The appeal is an essen-


Evaluation of Education Materials tial factor for evaluation because it assesses whether the material is culturally, gender, and age appropriate; if the material closely matches the logic, language, and experience of the intended audience; and if the material is interactive via questions or suggested actions for the reader. The variables in this study related to congruent patient factors and the essential evaluation factors are in Table 1. Two instruments were found in the literature that were specifically designed to evaluate the suitability of written materials: Area Health Education Council Assessment (Area Health Education Center [AHEC], 1996; Plimpton & Root, 1994) and the Suitability Assessment of Materials (Doak et al., 1996). Wilson (1999, 2000), in earlier studies, used both instruments and found them to be effective scales of measurements in determining the appropriateness of written patient education materials. These instruments were recently developed and require further testing to determine their psychometric properties. The AHEC assessment tool was used as a measure of the essential factors in the current study. The instrument is also user-friendly and comprehensive (Doak et al., 1996). Research Questions The following questions guided the study: 1. What is the mean self-report of highest grade completed in school for patients receiving radiation therapy treatment? 2. What is the mean actual reading and comprehension ability, as measured by the Rapid Estimate of Adult Literacy in Medicine (REALM) ( Murphy, Davis, Long, Jackson, & Decker, 1993) and the CLOZE technique (Taylor, 1953) respectively? 3. What is the average readability level of the RSEI cards used to teach patients about their radiation sideeffects? 4. Is there a discrepancy between the patients’ability to read and the readability of the RSEI cards?

71

Table 1 Evaluation of Components in the Model Factors congruent with the patient and his/her environment Basic conditioning factors Age* Gender* Education* Socioeconomic status* Sociocultural orientation* Health state Marital status Self-care agency (doing and knowing capabilities) Learner skills (patient learning needs and learning style) Reading* Writing Comprehension* Counting Perception Therapeutic conditioning factors Written information needed about radiation side effects—RSEI Cards* Essential evaluation factors Organization* Writing style* Appeal* Appearance* *Variables in this study related to congruent patient factors and the essential evaluation factors. NOTE: RSEI = Radiation Side Effect Information

Testing the Model A pilot study focused on the effects of oncology nursing education interventions to enhance and promote selfcare behaviors among patients experiencing radiation treatment side effects. The s t udy us ed a des cr i pt ive, correlational research design. Sample A total of 238 randomly selected patients receiving radiation treatment at two urban radiation oncology centers in the Midwest participated in the study. The patient treatment sites included head and neck (n = 31), lungs (n = 28), breast (n = 70), prostate (n = 75), other thoracic areas (n = 4), and other abdominal areas (n = 30). Additional information about the sample can be found in Table 2. Patient Education Materials A set of 40 RSEI cards were evaluated, according to the model, for suitability for patient education in the study. The cards addressed a variety of side ef-

fects that can occur during radiation therapy. These include fatigue, appetite disturbances, impotence, thrombocytopenia (bleeding: low platelet count), skin reactions for men, skin reactions for women, decreased fertility (male), bladder difficulties, changes in fertility, and alteration of menstrual cycle. Each patient was given a subset of cards according to the side effects (matched with their health state) for which they were at risk based on their treatment site. These cards were 8½ by 5½ inches, constructed of a strong, cardlike, cream-colored bond paper and used size 10 fonts. The information was printed on both sides of the card. They were consistent in the subtopics that included a description of the side effects and etiology, duration, self-care measures, other measures, and when to consult a radiation oncologist or nurse. The RSEI cards are used in a variety of national and international oncology centers and are commercially distributed, through Self-Care Media, Inc., to such countries as Australia and Belgium.


72

Nursing Science Quarterly, 16:1, January 2003 Table 2 Demographics of the Patient Sample

Patients Age (years) (missing n = 4) 20-30 31-40 41-50 51-60 61-70 >70 Gender Women Men Ethnicity African American Caucasian Other Income (n = 184) < $5,000 $5,000 - $15,000 > $15,000 - $30,000 > $30,000 - $50,000 > $50,000 - $75,000 > $75,000

n

%

6 12 39 55 73 49

3 5 16 23 31 21

119 119

50 50

125 107 6

52 45 3

19 47 35 40 26 17

10 26 19 22 14 9

Instruments Four instruments were used in the study to assess the essential factors: the REALM, the CLOZE technique, the SMOG test, and the AHEC Assessment Checklist. The REALM (Murphy et al., 1993), a reading test that measures word recognition, was used to analyze reading skills of the patients. The test consists of 66 words related to anatomy or healthcare. The test takes 10 minutes to administer. The REALM has been correlated with other standardized tests, namely, the Wide Range Achievement Test (r = .87) and the Peabody Individual Achievement Test (r = .97) (Murphy et al., 1993). The CLOZE procedure was developed by Taylor (1953) to measure reading comprehension. With this test, every fifth word is deleted from a written passage. The reader must then fill in the blanks. A general information passage, written at the fifth-grade level, was adapted to the CLOZE standards and used to examine comprehension in this study. A score of 60% or above indicates the reader was capable of understanding what was read; 40% to 59%

means the patient will need supplemental instructions to understand the information read, and a score below 40% means the material was too difficult for the patient to comprehend. In this study, the correlation between the REALM and CLOZE was .71. The SMOG (McLaughlin, 1969) is a readability formula used to measure the reading levels of written passages. The test, like other readability formulas, measures the number of multisyllabic words in a passage and, based on specific guidelines and conversion tables, yields an estimated grade-level score. Readability formulas have shown consistently high reliability (r = .75 to r = –.99) (Spardo, 1983). Researchers, however, stress caution against employing some of the readability formulas for analyzing health education materials because of their limitations. By definition, formulas only focus on syntax (the arrangement of words) and semantics (the choice of words). They do not consider the content of the material, use of technical language, or familiarity of the words to the reader (Meade & Smith, 1991). Other critics point out that the number of words or length of a sentence is less important than the complexity of the content in the text (Mayeaux, Murphy, Arnold, Davis, & Sentell, 1996). The SMOG, however, is highly recommended for evaluating health education materials (Meade & Smith, 1991). The AHEC (1996) Assessment Checklist is a 17-item tool used to evaluate the appropriateness of materials for unskilled readers. Any missing items from the checklist indicate that the material is likely to be inappropriate for low-literacy readers. The tool focuses on four attributes: organization, writing style, appearance, and appeal. The researchers were unable to find any psychometric studies related to the AHEC Assessment Checklist. Because of its face and content validity and its recognition by literacy experts as a viable tool (Doak et al., 1996; Plimpton & Root, 1994), it was a useful instrument for purposes of this study. For this

study, two raters knowledgeable about evaluating written patient education information reached 90% agreement to determine interrater reliability. The assessment checklist is user-friendly and required about 10 to 15 minutes to assess each document. Procedure The readability of the RSEI cards was analyzed using the SMOG. The AHEC (1996) Assessment Checklist determined suitability or appropriateness of the cards for teaching patients with limited reading skills. During a visit to the radiation oncology center, each patient in the study completed a demographic information profile, which assessed several of the BCF. Next, the patients’ reading and comprehension levels were assessed by the REALM and CLOZE, respectively. A member of the research team interviewed each patient to ascertain patient and family concerns and their experience with side effects or anticipated side effects. The information obtained from the interview guided the investigator in determining which RSEI cards were appropriate for the patient. Findings The BCF of age, income, gender, cultural orientation, education, and health state were assessed in the study. In addition, the SCA capabilities of reading and comprehension were also analyzed. The self-report of highest grade completed in school was a mean of grade 13 (SD = 3.3) or the equivalent of 1 year post–high school. The actual mean reading level score was 60 (SD = 12), which is consistent with 7th to 8th grade, as measured by the REALM. However, the distribution of reading scores were negatively skewed with 78% (n = 187) of the patients actually reading at the high school level or above and 22% (n = 51) of the patients reading between the 1st- and 8th-grade level (see Table 3). Patients’ ages ranged from 20 years to 87 years of age with a mean of 59 years (see Table 2).


Evaluation of Education Materials Table 3 Frequency Distribution of the Actual Reading Levels as Measured by the REALM

Table 5 Readability of Radiation Side Effect Information Cards Topic

Grade Level

Number of Patients (N = 238)

%

3 and below 4 to 6 7 to 8 High school

7 11 33 187

3 5 14 78

NOTE: REALM = Rapid Estimate of Adult Literacy in Medicine.

Table 4 Frequency Distribution of Comprehension as Measured by the CLOZE CLOZE Scores (%) 0 - 39 40 - 59 60 - 84 85 - 100

73

Number of Patients (N = 238)

%

46 69 123 0

19 29 52 0

The comprehension scores on the CLOZE ranged from a low of 0% to a high of 84%, of a possible score of 100%. The mean score of 54% (SD = 21) indicated that patients needed supplemental instructions to understand the written patient information they were given to read. The analysis showed that 123 patients (52%) understood the information they read and 115 patients (48%) in the study either needed supplemental teaching after reading the information or did not understand any of the information they read. The distribution of the comprehension levels across the group is shown in Table 4. Literacy experts generally infer that a relationship exists between comprehension and self-report of highest grade completed in school. This study showed that comprehension was unrelated to level of education (r = –.08, p > .05). Among patients reporting education at or above the high school level (n = 215; 90%), 52% demonstrated acceptable

SMOG Readability Grade Levels

Anemia: lowered red blood cell count Appetite disturbance Bladder difficulties Breast and arm swelling (edema) Brain radiation syndrome Change in fertility and the menstrual cycle Cough Decreased fertility (men) Diarrhea Difficulty swallowing: (pharyngitis, esophagitis, dysphagia) Dry mouth (xerostamia) Emotional reaction Hair loss (alopecia, epilation) Impotence Mouth sores Skin reaction (men) Skin reaction (women) Vomiting (emesis) Vaginal steniosis/vaginal dilation Nutrition information Nausea

levels of comprehension (CLOZE ≥ 60), but 48% needed supplemental instructions after reading the material or did not understand what they read. These results support the notion that highest grade completed in school should not be used as a measure to infer a patient’s comprehension abilities. Evaluation of Readability and Suitability of the RSEI Cards Twenty RSEI cards were analyzed for readability (see Table 5). The mean readability level was 11th grade (SD = 1.35). Although the side effect cards did not exceed the reading skills for the majority of patients in the study, there were a substantive number of patients who could not read them and needed supplemental instructions. The organization, writing style, appearance, and appeal of the information on the card were analyzed using the AHEC checklist. The first attribute, organization of the RSEI cards, was assessed. The cards began with an introduction, followed by a segment on duration, and then an explanation of self-care measures was presented (which is the need-to-know informa-

10 11 11 9 10 12 8 12 10 12 9 12 9 13 9 9 9 11 12 11 11

tion). In essence, the need-to-know information was positioned near the end of the cards rather than at the beginning as recommended. In addition, the cards exceeded the recommended 3 to 4 main points in the materials. In fact, the cards contained 6 to 10 self-care measures. Each RSEI card was consistent in layout of the materials and used subtopics such as description, duration, and self-care measures to guide the reader. The cards failed to summarize key points or expected behaviors stated in the documents. Writing style was the second attribute assessed in the RSEI cards. All the cards used the active or conversational style. Doak et al. (1996) stressed the effectiveness of conversational style of writing for better comprehension in that the reading level is automatically lower. Several examples were given to clarify suggested self-care actions. Some medical jargon was used in the materials, but the majority of the cards contained lay language and whenever medical or technical language was used, an explanation was presented in parenthesis. The text used a friendly tone.


74


Third, appearance of the materials was evaluated. The cards were plain in appearance and used uppercase and lowercase letters appropriately. There was a contrast between the black lettering and the cream-colored paper. However, there was little white space and the cards appeared cluttered with numerous words. The materials used a small font size of 10 point. The recommended font size for easy-to-read materials ranges from 12 to 14 point or larger depending on the target audience. A font size less than 12 points makes the card difficult to read, particularly for patients with limited visual acuity. The mean age of the subjects was 59 years with patients up to age 87 years, suggesting that a significant number of patients may have had difficulty reading the small print. Consideration for age-appropriate written materials include the recognition of the poor visual acuity associated with older patients. In addition, no illustrations or drawings were contained in the materials. The use of visual aids can assist the reader’s understanding of the message and can be a powerful way of matching for the patient’s age, gender, and sociocultural orientation. Fourth, the appeal of the materials for diverse groups was questionable. The cards were generic in their presentation and did not address cultural beliefs, behaviors, or lifestyles, which should be addressed in a test of the theoretical model. For example, sociocultural orientation includes factors such as ethnicity, culture, and beliefs. Because healthcare professionals have come to recognize the relationship between culture and health, written materials should convey information that is relevant to the target groups. A large number of patients in this study were African American, yet the materials did not address the language, health beliefs, health practices, and communication patterns of this group. The cards were, however, gender-appropriate in addressing topics such as skin problems, impotence, and fertility. In the area of appeal, the cards were very specific in suggesting self-care behaviors and were engaging for the reader.

Finally, the RSEI cards were developed to enhance the SCA of patients undergoing radiation therapy to meet the self-care demands (that is, TSCD) arising from the health deviation requisites (HDR). The content of the RSEI cards reflected the self-care requirements identified by nurses, physicians, and technicians who specialized in this treatment modality. The cards were written and reviewed by experts in Orem’s theory to ensure that the format and language were consistent with the goals of promoting self-care. Orem (2001) identified six HDRs (actions) that an individual may take when confronted with health problems. In this study, the RSEI cards focused on assisting radiation therapy patients to meet their TSCD, with emphasis on meeting the HDR of “being aware of or attending to or regulating the discomforting and deleterious effects of medical care measures performed or prescribed by the physician, including effects on development” (Orem, 2001, p. 235). Discussion The study demonstrated a comprehensive model for evaluating written patient education materials, which includes both essential factors from the health literacy literature as well as new theoretically derived concepts from the self-care literature. Shortcomings identified in the RSEI cards classified them to be less than ideal as a teaching tool for cancer patients with limited reading and comprehension skills. Following the patient assessment, the data showed the mean reading level in the study was between seventh- and eighth-grade level. The reading level of the RSEI cards was beyond the abilities of many of the patients in the study and exceeds the recommended sixth-grade level for the general public (National Work Group on Literacy and Health, 1998). Doak et al. (1996) suggest the fourth- to fifth-grade level for materials that target many urban patients. Different sets of RSEI cards should be developed for patients with low reading skills. More important, patients should

be examined for their comprehension of the material as many patients could read the cards, but lacked an understanding of the information. Simply asking the patients to explain, in their own words, what he or she read will let the provider know if the patient comprehended the information. The sample was skewed in that the majority of patients read at the high school level. The skewed results of reading levels were not surprising given the broad range of patients who receive radiation treatment from the large urban oncology center that served populations from diverse backgrounds. The sample included patients who were low income and poorly educated as well as patients who were better educated and more affluent. The written materials evaluated in the study, the RSEI cards, required a reading demand ranging from 8th- to 13th-grade level. Another important element in the model of determining suitability of written information is the comprehension skills, as measured by the CLOZE. The findings indicated that nearly half the patients would need supplemental instructions in order to understand education materials they were given to read. Inability to comprehend information about their health and treatment may increase patient anxiety and prevent patients from formulating questions for the healthcare provider or from making informed decisions. In terms of the RSEI cards, several shortcomings were noted in their organization, appearance, and appeal. The materials did not present the need-toknow information in the beginning sections of cards, did not use illustrations to convey the message, and were not culturally sensitive in their language or recognition of different cultural groups for whom the cards were targeted. Some of the guidelines for selecting or developing written patient education materials require professionals to alter many of their learned writing composition rules. For example, a traditional patient education pamphlet or brochure usually begins with an explanation about the disease or illness, followed by


Evaluation of Education Materials the causes of these conditions. When developing easy-to-read materials, this information would be presented later in the materials. The need-to-know information or the recommended course of action for a treatment or procedure would be presented in the beginning. Implications The selection of suitable patient education materials is becoming increasingly important given the proliferation of such materials currently available to the healthcare professional (Bernier, 1993). The model reported here offers nurses and other professionals a comprehensive conceptual framework for judging the appropriateness of the teaching materials they use. The results of the study have implications for further research. Nurses have an important role in helping patients find and use information that help in making healthcare decisions. Nurses’ responsibility for educating patients and families, combined with their advocacy for suitable education materials, place them in key positions for health teaching and assuring that information available to consumers is clearly understood. Patients who are knowledgeable can make independent decisions about their care, but that condition is threatened by a significant number of patients who are having difficulty understanding a major tool used to enhance patient knowledge, namely written patient education materials. The aims of patient education extend beyond dissemination of information. The overall intent is to provide patients with information and instructions that will enable them to achieve an optimal level of health and prevent risk. Consistent with the aims of patient education is the presentation of an evaluation model that can guide practitioners in determining whether the materials they use are congruent with the therapeutic self-care needs and self-care abilities of the patient. By combining the accumulated wisdom of health literacy experts with concepts of self-care,

nurses can provide a comprehensive strategy to choose and design the most effective written patient education materials. A number of researchers have begun to build a knowledge base centering on identifying suitable patient education material and instructional information, appropriate education content, methods of teaching, and stages of illness or health state when teaching is most effective. Further research is needed to provide scientific foundations of health education for patients with low literacy skills. Health professionals may not be able to alter some of the factors that affect health communication such as the patient’s literacy level, cognitive ability, language skills, formal education, and socioeconomic status; however, they are in a position to influence the understanding and comprehension of what is being taught (Doak, Doak, & Mead, 1998). References Airhihenbuwa, C. O., & Obregon, R. (2000). A critical assessment of theories/models used in health communication for HIV/ AIDS. Journal of Health Communication, 5, 5-15. Area Health Education Center (AHEC). (1996). The assessment checklist. Biddeford, ME: University of New England. Ayello, E. A. (1993). A critique of the AHCPR’s “ Preventing Pressure Ulcers: A Guide” as a written information tool. Decubitus, 6, 44-50. Bernier, M. J. (1993). Developing and evaluating patient education materials: A prescriptive model for quality. Orthopedic Nursing, 12, 39-46. Bernier, M. J., & Yasko, J. (1991). Designing and evaluating printed education materials: Models and instrument development. Patient Education and Counseling, 18, 251-263. C ont r e r a s , A . , G a r c i a - A l o n s o , R . , Echenique, M., & Daye-Contreras, F. (1999). The SOL formulas for converting SMOG readability scores between health education materials written in Spanish, English, and French. Journal of Health Communication, 4, 21-29. Doak, L. G., & Doak, C. C. (1980). Patient comprehension profiles: Recent findings and strategies. Patient Counseling and Health Education, 3, 101-106.

75

Doak, L. G., Doak, C. C., & Meade, C. D. (1998). Strategies to improve cancer education materials. Oncology Nursing Forum, 23, 1305-1312. Doak, L. G., Doak, C. C., & Root, J. (1996). Teaching patients with low literacy skills. Philadelphia: Lippincott. Flesch, R. (1948). The art of plain talk. New York: Harper & Row. Fry, E. (1977). Fry readability graph: Clarification, validity, and extension to level 17. Journal of Reading, 21, 242-252. Gunning, R. (1968). The techniques of clear writing. New York: McGraw-Hill. Hartmann, R., Draeger, J., & Berrnstein, M. (1991). Patient literacy training: A new challenge for patient education. Patient Education and Counseling, 17, 147-152. Hussey, L. C., & Gilliland, K. (1989). Compliance, low literacy, and locus of control. Nursing Clinics of North America, 24, 605-611. Kirsch, I. S., Jungleblut, A., Jenkins, L., & Kolstad, A. (1993). Adult literacy in America: A first look at the results on the National Survey of the National Literacy Survey. Washington, DC: United States Department of Education. Mayeaux, E. J., Murphy, P. W., Arnold, C., Davis, T. C., & Sentell, T. (1996). Improving patient education for patients with low literacy skills. American Family Practice, 52, 205-211. McLaughlin, H. G. (1969). SMOGGrading: A new readability formula. Journal of Reading, 12, 204-206. Meade, C., & Smith, C. (1991). Readability formulas: Caution and criteria. Patient Education and Counseling, 17, 153-158. Mood, D. W., & Bickes, J. T. (1992, January-February). Nursing interventions to promote self-care. Paper presented at the American Cancer Study Society Second National Conference on Cancer Nursing Research, Baltimore. Mood, D. W., Horowitz, L., & Chadwell, D. (1987). Increasing patients’ knowledge and self-care during radiation therapy. Oncology Nursing Forum, 14 (suppl.), 153. Murphy, P. W., Davis, T. C., Long, S., Jackson, R., & Decker, B. (1993). Rapid estimate of adult literacy in medicine (REALM). Journal of Reading, 37, 124-130. National Work Group on Literacy and Health. (1998). Communicating with patients who have limited literacy skills. The Journal of Family Practice, 2, 168-176. Orem, D. E. (1971). Nursing concepts of practice. New York: McGraw-Hill. Orem, D. E. (1991). Nursing concepts of practice. New York: McGraw-Hill.


76


Orem, D. E. (2001). Nursing concepts of practice. New York: McGraw-Hill. Plimpton, S., & Root, J. (1994). Materials and strategies that work in low literacy health communication. Public Health Report, 109, 86-91. Redman, B. K. (1997). The practice of patient education (8th ed.). St Louis, MO: Mosby. Rice, M., & Valdivia, L. (1991). A simple guide for design, use, and evaluation of education materials. Health Education Quarterly, 18, 79-85. Riley, M. W. (1963). Sociological research: Volume 1. New York: Harcourt, Brace, & World.

Roth, E. (1976). A ferment in education. American Education, 12(4), 6-9. Spardo, D. C. (1983). Assessing readability of patient education materials. Pediatric Nurse, 9, 274-278. Streiff, L. (1986). Can clients understand instructions? Image: Journal of Nursing Scholarship, 18, 48-52. Taylor, W. L. (1953). CLOZE procedure: A new tool for measuring readability. Journalism Quarterly, 30, 415-433. Wagner, D., & Venezky, R. (1999). Adult literacy: The next generation. Educational Researcher, 28, 37-38. Weiss, B., Hart, G., McGee, D. L., & D’Estelle, S. (1992). Health status of il-

literate adults: Relations between literacy and health status among persons with low literacy skills. Journal of American Board of Family Practice, 5, 257-264. Wilson, F. L. (1999). The suitability of United States Pharmacopoeia Dispensary drug leaflets for urban patients with limited reading skills. Archives of Psychiatric Nursing, 13, 204-211. Wilson, F. L. (2000). Are patient information materials too difficult to read? Home Healthcare Nurse, 18, 107-115.
