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There is a good evidence base in the literature for the use of written patient information in healthcare settings to enable patients to retain information concerning procedures and treatments following initial consultations. A number of tools exist to help in the design of written patient information. These include checklists such as the Department of Health Toolkit for Producing Patient Information, EQIP and DISCERN tools, readability scores such as the Flesch-Kincaid Formula and Flesch Reading Ease score, as well as cultural sensitivity scores. These tools are presented and their possible role in dental primary care discussed.
Clinical Relevance: The tools provided here will enable clinicians to develop a better standard of patient information literature concerning procedures and treatments on offer.
Article
Ross OC Elledge
Research has demonstrated that patients only retain a fifth of the information imparted to them at any consultation, with evidence of improvement by as much as 50% when supplemental written information is provided.1 There is a growing evidence base in the literature for the use of patient information leaflets in dental practice. The use of these has been shown to correlate well with improved information retention by patients, aiding informed consent for procedures such as wisdom tooth removal, orthodontics and implant surgery, as well as reducing anxiety in patients in general.2–5 In particular, there has been shown to be a role for leaflets in cultivating public awareness of oral cancer risk factors and screening.6 Whilst guidance exists from the Department of Health and the General Medical Council on the provision of patient information in the medical setting, no similar guidelines exist for general dental practice.7,8 Lewis and Newton have highlighted a trend of patient information literature in primary dental care that tends to exceed the standards of recommended readability to suit the average patient, whilst falling short of standards expected of the Royal National Institute for the Blind (RNIB) and universally established good practice criteria, such as clearly stating aims and citing sources.9 There are a number of considerations to be made in designing patient information leaflets beyond these, and a number of evaluation methods exist to ensure that these are met.
Good practice guidelines
Department of Health Toolkit
The Department of Health published a toolkit in 2003 to lay down the essentials of good practice in shaping patient information literature.7 This provides a number of transferable recommendations relevant to all patient information literature, from advice on elements such as font size to the avoidance of jargon and use of everyday language. It also features a number of checklists to help with writing patient information leaflets about:
Operations;
Treatments and investigations;
Conditions and treatments;
Services; and
Medications.
These checklists could easily be used in a dental setting and it is easy to see how the first of these checklists (Figure 1) could be applied to providing written information regarding a procedure in primary dental care, such as wisdom tooth removal.
Figure 1. Checklist for writing information about operations, treatments and investigations (from Department of Health Toolkit for Producing Patient Information, 2003. Crown copyright, 2003).
Ensuring Quality Information for Patients (EQIP)
The Ensuring Quality Information for Patients (EQIP) tool was designed by Moult et al based on recommendations on good standards of written information for patients informed by a comprehensive literature search.1 Recommendations included the use of shorter sentences, a respectful tone and easy-to-understand illustrations, amongst other considerations that are reflected in the final EQIP questionnaire (Figure 2).
Figure 2. Questions from the Ensuring Quality Information for Patients (EQIP) tool (adapted from Moult, et al1).
Assessment of the tool showed a good inter-rater reliability and good correlation with the judgement of experienced clinicians and the forerunner assessment tool, DISCERN.1 EQIP has an additional advantage in that scores derived from it serve to recommend what action to take with existing patient information leaflets. It would be easy to see how the EQIP tool could be used in dental practice to design patient information leaflets based on its track record in settings as diverse as skin cancer and sun protective behaviour and consumer cancer information.10,11 A recent revision by Charvet-Berard et al has added a further 16 items to the original 20 item scale shown here.12
DISCERN
The DISCERN tool is another device that can be used both to assess existing patient information literature and as a checklist for the provision of replacement literature. The tool consists of 16 questions dealing with particular features expected of written information for patients, as well as an overall quality appraisal in the final question. Questions 1–8 deal with reliability of information provided, whilst questions 9–15 deal with specific information regarding treatment choices. Answers are given in terms of a rating on a five-point scale (Likert item) in terms of how well each expectation is met.13 The tool has shown good inter-operator agreement, which has tended to be more consistent when used by healthcare professionals with training in its use.14 Many of the questions are generic and easily applicable to the dental setting and the fact that the tool is easily accessible online would make it readily available in dental practice.15 Furthermore, workshops on the use of the instrument, which are advertised on the DISCERN website, may be counted towards continuing professional development (CPD) requirements.16
Readability scores
Readability assessment is of paramount importance in the provision of patient information when one considers that 52% of the British working-age population have a literacy level equivalent to an 11-year old child or younger.17 Given this figure, this would probably be the standard for most practitioners to aim for when writing in-house patient information leaflets, although clearly the patient demographic served by a particular clinic may determine the appropriate readability score. Lower socioeconomic status areas may have poorer literacy levels, with an ironically greater need for patient information when making healthcare choices.18
There are a number of manual and computerized methods that can be employed to assess the readability of a text, often based on components such as the average number of syllables per word and number of words per sentence, both of which have been shown to correlate strongly with ease of reading.19
Flesch-Kincaid (F-K) Formula
The Flesch-Kincaid Formula is a commonly used computerized method which returns a score that equates to a US grade-school level reading standard.20 A score of 8.0 therefore would correlate to an eighth grade reading ability, or that of an average student between the ages of 13 and 14. The formula to calculate the F-K score is shown below:
Flesch Kincaid Score = (0.39 x ASL) + (11.8 x ASW) – 15.59
Where ASL is the average sentence length and ASW is the average number of syllables per word.
Flesch Reading Ease Score (FRES)
The Flesch Reading Ease Score (FRES) returns a score between 0 and 100, with a higher score equating to a more easily readable text. The formula for calculation is shown below:
FRE score = 206.835 – (1.105 x ASL) – (84.6 x ASW)
One further readability score that deserves mention is Simple Measure of Gobbledygook (SMOG) score as first published by McLaughlin in 1969.21 Popular in British literature, this score is conducted on 10–30 sentences in a sample of writing and again hinges on the number of polysyllabic words, returning a score of 3–8 for a reading age appropriate for primary education, 9–12 for secondary education and 13+ for tertiary education. A SMOG score of less than or equal to 5 has been recommended for the standard in health literature for patients.22
Many other readability scores exist. It should be remembered, however, that readability is only one element that facilitates patient understanding of information, along with other variables such as cultural appropriateness, linguistics, formatting and text legibility.23 Previous experience and motivation, along with knowledge procedures allowing patients to derive significance from a given text, are unmeasured quantities in simple readability scores.24 Readability formulae are available in commonly used computer software, however, such as Microsoft Word, making them easily available and time efficient adjuncts to designing patient information. They are not without their limitations, however, as they can only assess readability and not writeability, a trap healthcare providers may unwittingly fall into in constructing nonsensical paragraphs from shorter sentences of monosyllabic words in the pursuit of ‘better’ readability scores.25
Cultural sensitivity
An important consideration in an increasingly multi-cultural society in the United Kingdom is that patient information should be culturally sensitive, that is it should be targeted to the ethnic/cultural norms of the patient population for whom it is intended.26 This is especially important in the provision of written information for oral cancer, for instance, where ethnic groups may have their own risk factors that require addressing.27 Cultural sensitivity has been defined by Resnicow et al as two dimensional, having superficial and deep structures. Superficial structure refers to people, places, clothing, etc preferred by a particular target audience, whilst deep structure refers to ‘cultural, social, historical, environmental and psychological forces’ that influence the behaviours, beliefs and healthcare perceptions of a group.28 Few formal scores for assessing the cultural sensitivity of written patient information exist and those that do tend to be specific to particular situations. Once again, however, many of the points from these can be transferable to situations in dentistry, as with the points raised by the Cultural Sensitivity Assessment Tool (CSAT) designed by Guidry et al and the extended checklist by Friedman and Hoffman-Goetz (Figure 3).29,30
Figure 3. Questions for assessing the cultural sensitivity of information (adapted from Friedman and Hoffman-Goetz30).
Summary
In summary, therefore, we can see that, whilst there may not be a wealth of guidelines pertaining to providing information for patients in dental practice, the standards are clearly transferable from the medical literature. The author himself has been involved in re-writing a leaflet for patient advice regarding open reduction and internal fixation of fracture mandibles (Figure 4) and found the application of a number of different tools of greatest benefit. Clearly, the different tools target different elements of patient information leaflets and will yield the best results if used in combination. The readability scores all have an evidence base, but the SMOG score may be easiest to interpret as it relates most directly to the United Kingdom education system.
Figure 4. Comparison of an excerpt from a leaflet advising patients about surgery for the fixation of a fractured mandible, comparing old (left) and new (right) leaflets. Notice how the example on the right has an obviously superior readability score, uses jargon-free, personal text and incorporates an illustration in a more attractive appearance. This exemplifies a number of points from both the EQIP tool and readability scores working together.
In an information intensive society where patients expect better answers to well-informed questions, patient information documents may go a long way to allaying anxiety and reinforcing the patient-clinician relationship. The tools dealt with in this publication will hopefully allow the dental practitioner to ensure that the highest standards are met in providing this information.
