Background It is common practice for information leaflets to be given to people attending hospital after a head injury. Their role is potentially important in alerting the patient or their family to possible undetected or late-emerging cerebral complications in addition to providing guidance aimed to reduce the risk of further injury, or negative social or employment outcomes during recovery. This study examines the readability of information sheets provided by emergency departments in all Scottish hospitals.
Methods Discharge advice leaflets pertaining to head injury from every ED in Scotland were obtained (45 leaflets from 30 hospital sites). Readability was assessed using two recognised formulae (SMOG and FRE). Legibility was assessed using the Royal National Institute for the Blind Clear Print Guidelines. Content was compared to the Scottish Intercollegiate Guidelines Network (SIGN46) recommendations on the early management of head injury.
Results and discussion It is estimated that less than 30% of the population would understand more than 90% of the head injury leaflets. Fewer than half of the leaflets provide even half of the patient information recommended by SIGN46. Analyses of other indicators from clear print guidelines are presented, together with a recommended format for a head injury leaflet and a metric is proposed for evaluating the usefulness of patient information leaflets in general.
- Emergency care systems
- emergency departments
- risk management
- prehospital care
- patient support
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- Emergency care systems
- emergency departments
- risk management
- prehospital care
- patient support
Head-injury attenders at hospital are common, and most are not admitted or are discharged within 24 h. In Glasgow, there were 340/100 000 populations admissions with head injury in 1 year, most of whom sustained a mild or moderate head injury.1 The Scottish Intercollegiate Guidelines Network (SIGN 46)2 provides advice on management in the first 72 h after a head injury, and recommends that patients (or an accompanying adult) receive an information leaflet on discharge describing what to do should certain symptoms occur. The purpose of this is to alert the patient and their family to the possibility of undetected or late emerging cerebral complications, to reduce risk of further injury or negative social or employment outcomes during recovery, and it is also recognised that reassurance and education reduce the likelihood of persisting symptom complaint.1–3
In order for the guidance to be followed, it is clearly important that the readability of the leaflets is considered. Approximately 800 000 adults in Scotland have low levels of literacy and numeracy.4 The Royal College of Physicians of London recognises that ‘written information in a form which is easily understood by the patient can be invaluable.’5 However, many information leaflets for patients are written to university or postgraduate level, and the nature, extent and quality of information provided in a third of all patient information leaflets are at a level that cannot be understood by the general population.6–8 The impact of plain language materials on people with limited literacy is often not considered. Even in a study on a population with reading skills at high school level, a ‘Simplified’ head injury advice leaflet, was preferred to a ‘Standard’ version and was better understood.9 Clearly, demographic factors such as socio-economic status, education and intellect in the population for which the information is intended need to be considered.10 For example, there appear to be poor literacy levels in emergency department populations. This could be a factor in the relatively poor comprehension and memory for discharge information in attenders with head injury.3 8 11 A number of other factors seem to be important when considering whether information is likely to be understood. Many people cannot understand print materials alone, and additional means of communication are essential. Other factors include the use of colours, font, print size, layout and readability.12–14
There are a number of formulae designed to assess the reading skills needed to read a document.15 Readability is often confused with legibility, although legibility is important in the wider context of readability. Readability itself is defined by a number of mathematical indices and is formally evaluated with formulae that most often measure combinations of average word length, polysyllabic frequency and average sentence length with varying weightings; some indices discount proper nouns, and others still include a count of ‘difficult’ words against an exhaustive list. These indices were developed from different publishing requirements, and different formulae were developed to be more appropriate for specific types of literature. Although different formulae can produce varying results,15 previous work shows that results correlate highly with each other.16 All readability scales in this study have been recommended at some time for use with health publications. The Flesch Reading Index (FRE) is perhaps the most universally accepted scale, although the SMOG is sometimes preferred over the others as a more rigorous test for evaluating medication information.13 Meade and Smith16 recommend the Simplified Measure of Gobbledygook (SMOG) formula: the rationale being that SMOG's widespread use and its reputation for reading level accuracy, simple directions and speed of use are well documented.
The present study analyses the readability of discharge information given to those with a head injury on discharge from emergency departments (EDs) throughout Scotland. It also suggests the format of an information leaflet that complies with standards for content and readability.
Materials and methods
In a recent study,17 discharge-advice pamphlets were obtained from every ED in Scotland, including three from dedicated children's EDs. These were used as the material basis for the present study. There were in total 45 leaflets from the 30 hospital sites. Four ‘types’ of leaflet were found. These were designed for: adult (16), carer (2), combined (8) and child (19). However, all four leaflet types were intended for an adult reader (in the role of patient, carer, parent or guardian), and hence all 45 leaflets were analysed together.
Two measures of readability were used. The FRE is a very widely used readability measure, whereas the SMOG has a reputation for reading-level accuracy, simple directions and speed of use16 as well as being a rigorous test for evaluating medication information.13 Readability indices were evaluated using Readability Studio, 2007, v 1.2.0 software. Scores from the readability indices were calculated and used to estimate the IQ level required to understand the information leaflets. These figures were compared with Scottish literacy levels.4 Each leaflet was examined in terms of font size, layout, colour of paper, and use of images and diagrams, and measured against RNIB clear print guidelines.18
Most readability indices have been developed in the US and calculate a US School Grade Level equivalent from which a reading age is derived. There are differences in the US and Scottish education systems. Although no formal study of equivalence was found, anecdotal evidence suggests that the reading age of children in the UK is more advanced by perhaps 18–24 months, that is, a UK Reading Age of 10 would be equivalent to a US Reading Age of 11½–12. SMOG-US Grade levels 3–8 are equivalent to the reading ability of people with a UK primary education reading level and SMOG-US Grade levels of 9–12 to a reading ability of people with a UK secondary education reading level.19
FRE Scores indicate that the readability of the leaflets is poor overall (mean 60.1, sd 11.3). Table 1 uses verbal descriptors from Flesch's original 194915 table. On this basis, less than 30% of the population are likely to understand over 90% of the available leaflets. An IQ of over 100 is needed to understand more than 50% of the leaflets (see table 1).
It is recommended that health literature be written at a SMOG-US Grade Level of 5 or less if it is to be understood by most people.20 None of the head injury leaflets achieved this, all having ratings of 8 or more. SMOG-US Grade levels 3–8 are equivalent to reading ability of people with a UK primary level education and 9–12 to a reading ability of people with secondary education in the UK19 (see table 2).
Leaflets were assessed for legibility using the Royal National Institute for the Blind (RNIB), Clear Print Guidelines.18 These list 17 criteria for best practice (see table 3). The mean compliance level across the RNIB guidelines was 78%. However, several leaflets were poor on fundamental criteria such as minimum font size and paper thickness. If text is not fully justified, this spreads words across the page unevenly, making them more difficult to read; over 75% did not comply with guidance on text justification.14
Leaflets did not comply with best practice14 in the following ways: in 70% of leaflets, text was not dated (ie, to ensure advice is current), leaflets were not offered in a second media format or other languages in 93% of cases, and advertisements were used to fund the publication of 20% of leaflets.
‘Compliance’ was calculated by scoring each item recommended for inclusion in an information leaflet by SIGN 46 as either ‘0’ for omission or ‘1’ for inclusion, and then calculating the frequency count as a percentage of the total SIGN 46 score. Fewer than half of the leaflets provide even half of the patient information recommended by SIGN 46. Compliance was calculated slightly differently for the different types of leaflet—for example, those for child head injury were not penalised for not including guidance to avoid alcohol or avoid driving.
Recommended information leaflet (see appendix)
This leaflet complies with SIGN 46 guidelines. Its SMOG score is 9.0, and its FRE score is 71. This represents a ‘Fairly Easy’ level of reading (see table 1); about 80% of the population could comprehend the content. The leaflet also complies with best-practice guidelines published by RNIB18 and includes meta-data (eg, version number, print date, etc) to ensure that the information being distributed is the most current.
Readability analyses indicate that most head injury leaflets in Scotland require revision in order to be understood by the majority of the general population. The FRE scores indicate that 50% of the leaflets require an IQ of at least 100 to be understood. Five and a half million people in Britain have reading difficulties, and considerably more have low levels of literacy.20 There are 2 million individuals in the UK (Royal National Institute for the Blind) with sight difficulties, and the Clear Print Guidelines can help make information accessible to some people with a sight problem. Just under half of the patient leaflets did not conform to guidelines about type size, and 76% of leaflets were fully justified, making the text more difficult to read. Furthermore, the demographics of attenders at the ED with a head injury make them more at risk of having difficulty reading.1 3 Many patient information leaflets have been written to university or postgraduate level,6 and those for head injury in Scotland are no exception. Specifically with regard to mild head injury, it is recognised that persisting symptom complaint can be reduced by relatively simple procedures, including reassurance, education and advice.21 22 Clearly, provision of written information in a form that is easy to understand is a fundamental component of good management.
Readability formulae have limitations given the complexity of the reading process. Ideally, leaflets should also be piloted on their target group to inform more directly about their utility.19 Formulae based on word length might disregard patients' familiarity with the vocabulary associated with their injury, thereby overestimating the difficulty of the text. Many of the head-injury leaflets performed poorly on readability tests because of sentence length. Although readability is essential for basic comprehension, there are other concepts that contribute to the usefulness of health education materials, including content, clear graphics, layout and typography in addition to perceived utility and cultural appropriateness. SIGN 46 also recommends that there be accompanying advice from a healthcare professional on discharge. Even if an ideal leaflet is produced, it must of course be routinely given to the patient following a head injury. Something as simple as poor photocopying can render a good leaflet less effective by reducing its legibility or simply by making its general appearance give a patient an impression that it is unimportant.
Guidelines need to be produced that recommend clearer standards for validating the utility of patient literature. A new measure for patient literature is required that takes a more holistic approach to the problem of readability. It is suggested that this statistic be known as the PLUI (Patient Literature Usefulness Index). Since the formal definitions of readability do not take into account the use of the passive voice, the use of the second person rather than the third and adherence to widely recognised standards for legibility such as those published by the RNIB, there is clearly a need for a statistic such as PLUI (see table 4). PLUI is designed to be a guide to the overall effectiveness of literature in the general population. PLUI will return a value between 0 and 100, with 100 being the theoretically perfect patient information leaflet. In our recommended example of an information leaflet, the PLUI is 89%. Clearly, the weightings of items A–D in the table are suggestive and require validation by further study.
As a minimum, it is suggested that in future, all patient literature undergoes prepublication screening where a number of measures are taken and in particular that the readability is examined. Standard software is available that could automate the process and reduce the costs required to include this feedback loop in the publication process.
In summary, information leaflets given to patients on discharge from emergency departments following a head injury are largely not appropriate to literacy levels within the Scottish population. A holistic approach is important when developing patient information leaflets in order that the factors that reduce the effectiveness of the literature are minimised, namely, legibility, readability in the context of the target population, RNIB-CPG and basic information.
Thanks are due to I Swann for comments on an earlier draft of the manuscript. We are also grateful to the education subgroup of the National Managed Clinical Network for Head Injury for correspondence regarding information leaflet style and content.
Competing interests None.
Provenance and peer review Not commissioned; not externally peer reviewed.
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