Approximately 90 million adults in the United States have low health literacy (HL), making it difficult to navigate the health system and understand health information (Morrison et al., 2013). The pediatric population is especially vulnerable to this challenge, as caregivers with low HL practice inappropriate health behaviors that impact children (May et al., 2018). More than 20 million children in the United States are seen in the emergency department (ED) annually for nonurgent issues such as fever management (May et al., 2018). Low HL influences how caregivers respond to a child's fever and its management, often leading to frequent ED visits or inappropriate medication dosing (Monsma et al., 2015). Therefore, to address low HL, it is vital for nurses to be skilled at patient education.
According to Flanders (2018), patient education is a complex process; teaching patients and families is crucial to the practice of nursing and should be guided by evidence. Although patient teaching is a large piece of the nursing practice process, nurses often are not provided adequate opportunities to enhance this skill while enrolled in nursing coursework. Therefore, nurse educators and professional nursing development professionals must ensure all nurses are well trained and knowledgeable to identify patients who are at risk for HL deficits or who have low HL.
Issues related to low HL among Americans is evident, making it imperative to health promotion that all nurses gain understanding on how to educate patients and their caregivers. The Patient Protection and Affordable Care Act of 2010 defines healthy literacy as an individual's ability to “obtain, communicate, process, and understand basic health information and services to make appropriate health decisions” (Centers for Disease Control and Prevention [CDC], 2019). The Agency for Healthcare Research and Quality (AHRQ, 2018) reported that only 12% of Americans have the capacity or proficiency to understand and act on health information. Moreover, this capacity is further diminished in times of stress, for example, when struggling to comfort a sick child (AHRQ, 2018). Adults with low HL account for approximately one-third of the total population of caregivers who bring their children to the ED (Morrison et al., 2013). Paasche-Orlow and Wolf (2007) examined the causal pathways of the HL-health outcomes relationship. Socioeconomic factors, race, ethnicity, and potential sensory deficits impact an individual's capacity to obtain and understand information (Paasche-Orlow & Wolf, 2007). In addition, varying factors involved in caregivers' process of accessing and using health care, interaction with providers, and ability to participate in self-care is affected by an individual's HL level, which ultimately impacts health outcomes (Paasche-Orlow & Wolf, 2007).
Health systems on all levels have made providing quality care and reducing health care costs a priority (Neuman et al., 2014). Often, educational programs or improvement projects are introduced to achieve these goals and improve health outcomes. Fever management programs, for example, assist with encouraging and empowering caregivers in performing the skills needed to effectively manage a child's fever by increasing their level of knowledge and minimizing fear (Alqudah et al., 2014). These programs have resulted in increased knowledge of fever (29% to 54%), proper skills in fever management (13% to 46%), and decreased nonurgent ED use (13% to 30%) (Alqudah et al., 2014).
In 2004, Broome and Deupree developed the Assess-Communicate-Treat (A.C.T.) tool. The A.C.T. tool is a 25-page guide to help caregivers in a rural community dispel myths about fever, understand the parameters of fever, and determine the best course of action for management. This tool is a prime example of the effort nurses have taken to address low HL and improve patient education. The study to develop the tool and analyze its effectiveness was combined with formal educational classes to confirm caregivers received thorough teaching (Deupree et al., 2005). Although the tool followed best practice guidelines for fever management, some parameters for fever management have changed since the development of the tool 18 years ago. Therefore, the aim of this quality improvement project was to revise and validate the content of the tool to align with current HL standards and pediatric parameters for fever management with the aid of evidence-based HL models.
The initial planning meeting for this project included five master's-prepared nurses, one physician, one hospital executive, one baccalaureate-prepared nurse, and one doctorally-prepared nurse who is also an expert in HL continuing education and professional development. During the meeting, team members reviewed the original A.C.T. tool and discussed its importance to HL, relevance of the project, methods to recruit nursing staff participants, and ways to actively involve inpatient caregivers. Approval for this project was obtained from the University of Alabama at Birmingham Institutional Review Board.
Sample and Setting
A convenience sample led to the formation of two expert groups on fever management. The groups consisted of 18 RNs and six nurse practitioners (NPs) experienced in fever management and employed at an urban pediatric hospital urgent care setting. A presentation to each group provided information regarding the importance of HL, description of the current problem, and the purpose of the project. Participation was voluntary.
The pediatric hospital is actively engaged in initiatives to improve the culture of HL within the organization by involving the caregivers' council. The caregivers' council is a multigenerational and multicultural group that addresses issues affecting parents and caregivers of patients in the health system. Following updates by the two expert groups via a survey, a focus group was established and included the target audience of caregivers who were invited to volunteer for participation in the project via the caregivers' council leader. To encourage participation, the A.C.T. project team scheduled the caregiver focus group meeting and presentation at noon and provided lunch for all caregivers in attendance.
Design and Data Collection
A mixed-methods approach was used to examine content validity of the A.C.T. tool through a four-phase validation process. Two expert groups of trained professional nurses (RNs and NPs) provided content validation for the A.C.T. document. Nurses participating in the study had 2 weeks to complete the survey following a presentation where they learned about the survey and its purpose, and were allowed time for questions and answers. After updating the tool with suggestions from the expert groups, a caregiver focus group provided insight on the understandability, readability, and overall usefulness of the tool. A PowerPoint® presentation was used for the caregiver group, which allowed for real-time feedback and discussion.
A 4-point Likert scale was used to measure content validity. RNs and NPs were asked to rate attributes as 1 = appropriate, 2 = somewhat appropriate, 3 = somewhat inappropriate, and 4 = not appropriate at all and needed to be revised. Qualitative data were collected through comment sections on the survey. Recorded data were cross validated for completeness and accuracy to ensure interrater reliability (Kelly et al., 2016).
RN Expert Group
The expert group of RNs (n = 18) examined the original A.C.T. tool for content accuracy and presence of essential attributes for fever management. Each participant received a copy of the 71-item tool with a survey. The survey listed each item with a column for the 4-point Likert scale rating and a column for comments. Using the 4-point Likert scale, respondents were encouraged to provide comments and offer suggestions for improvement of each item. Survey results were coded for thematic analysis to ensure content validity leading to the development of a second draft of the tool. During analysis, items deemed not appropriate (3 or 4 on the Likert scale), along with the qualitative data, were used to guide revisions. Recommendations and comments from the RN group resulted in the revision of 17 items and the addition of one item. After revision, a survey with 72 items was forwarded to the NP group for review.
NP Expert Group
The NPs (n = 6) examined the revised A.C.T. tool over a 2-week period for content accuracy and presence of essential attributes for fever management. Each participant received a copy of the revised tool with 72 items along with the same survey used for RN feedback. Respondents ranked the appropriateness of each item using the same 4-point Likert scale and were encouraged to provide comments and offer suggestions for improvement of each item. Survey results were coded for thematic analysis to ensure content validity before revision for the second draft. Using NP feedback, 72 items were further revised, and one item was eliminated, leaving the tool with 71 items for a total number of 45 revisions and one item eliminated. After revisions, the tool was formatted for the caregiver focus group using a PowerPoint® presentation to facilitate easy discussion among the group as each slide advanced.
Caregiver Focus Group
A face-to-face focus group provided caregivers (n = 5) the opportunity to review the tool, view images and wording, and provide feedback in real time. The lead team member of the A.C.T. project navigated through the PowerPoint® presentation, taking time to read each item on the screen to the group. The caregivers then were asked their thoughts on each item after it was read. Group and individual responses were collected for each item. Two team members recorded all comments and responses; cross analysis to validate the understanding of the information recorded was completed to ensure interrater reliability. Results were coded for thematic analysis to develop the final version of the A.C.T. tool. Using HL best practice tools, final evaluation was completed to ensure the revised tool met the needs of the target audience for readability, understandability, and usability.
Evidence-Based Tools to Measure Patient Education Materials
Simply Put Analysis. The Simply Put tool guides health care organizations when developing educational materials to ensure principals for HL are used (CDC, 2009). The tool was used to guide the revision of the A.C.T. fever management guide to promote a clear message, chunk information by listing one idea at a time, provide information to caregivers regarding actions they should take for their child based on the situation, and remove references to statistics and medical jargon. In addition, uniform 14-point Times New Roman font, simple headings, and concise language, along with minimal use of bold print, were used in revising the A.C.T. tool.
Simple Measure of Gobbledygook (SMOG)/Flesch-Kincaid Grade Level (FKGL) Analysis. The SMOG readability formula (McLaughlin et al.,1969) and the FKGL (Kincaid et al., 1975) were used to measure the readability of the A.C.T. tool. The Centers for Medicare and Medicaid Services (CMS, 2012) promotes using readability tools to ensure educational materials are clear and concise. The SMOG readability formula measures how challenging sentences are to read based on the number of syllables of words (CMS, 2012). Words with no more than two syllables are considered understandable and easier to read (CMS, 2012). The FKGL is another readability formula embedded in Microsoft® Word that was used to measure the readability level of the A.C.T. tool. Results of both tests revealed the A.C.T. tool was written at a fifth-grade level. Therefore, the A.C.T. tool was determined to be understandable for a 10-year-old child or an adult reading at a fifth-grade level.
Patient Education Materials Assessment Tool Analysis (PEMAT-P). The PEMAT-P (2017) contains 26 questions (19 for understandability and seven for actionability) with the answer choice being either “disagree” or “agree.” Questions that did not apply due to limited content were documented as “very short material.” Each item analyzed was assigned point values: disagree (0), agree (1), or very short material (NA). Results of the PEMAT-P demonstrated the A.C.T. tool was 88% understandable and 83% actionable. The tool scored well on most items; however, caregivers are required to perform a calculation when taking the child's axillary temperature, and the A.C.T. tool failed to provide a summary of directions on how to perform the calculation, which caused points to be deducted. Because the revised A.C.T. tool met the threshold of the PEMAT-P (2017) guidelines, revisions were deemed complete (Table 1). The final version of the A.C.T. tool with revisions from the expert and focus groups refined the tool using best practices for HL when creating patient education materials and was shared with hospital administration. Discussion continues to determine the best way to use the fever management tool.
Revisions were made to attributes under each heading of the A.C.T. tool using suggestions and critiques from the expert panels and caregiver focus group. A total of 45 items were identified and revised based on feedback from the expert panels. Suggestions from the caregiver focus group led to the recommendations for the development of a prototype 11- × 14-inch laminated, two-sided document entitled “When to Call the Provider” on one side and “When to Go to the ER” on the other, along with dosing information and provider contact information.
The goal of the A.C.T. tool is to provide easy-to-understand information for caregivers regarding fever management along with strategies to manage fever effectively. To accomplish the goal of the tool, Simply Put (CDC, 2010), PEMAT-P (2017), SMOG (McLaughlin et al., 1969), and FKGL (Kincaid et al., 1975) readability formulas were used to ensure the document was understandable and actionable for caregivers. An easy-to-read, 20-page A.C.T. tool was recreated after all of the revisions were agreed on and the HL analysis was complete. Administration team members, including the chief medical director for the facility, provided feedback for the final document.
Since the A.C.T. tool was first developed in 2004, nonurgent ED visits for fever management continue to be problematic for both caregivers and healthcare systems. These preventable visits and hospitalizations cost the United States more than $200 billion annually (May et. al, 2018). Patients with limited literacy had 2.3 times the number of preventable ED visits resulting in hospital admissions compared with individuals with adequate HL, 1.4 times the number of treat-and-release visits, and 1.9 times the number of total preventable ED visits (Balakrishnan et al., 2017). Deupree et al. (2005) reported parental perception and knowledge of fever significantly improved for caregivers of children ages 6 months to 6 years with the initiation of the A.C.T. tool among a small group of caregivers in a rural Alabama community (N = 30). Nursing administration at the urban pediatric hospital were interested in methods to decrease return visits for fever management. They became aware of this tool in 2018 and expressed an interest in exploring the revision of the A.C.T. tool to facilitate a low HL-friendly method for increasing caregiver knowledge of fever management.
The opportunities to further HL research and practice are significant, considering the policy initiative set forth in the Patient Protection and Affordable Care Act (2010) and the Plain Writing Act of 2010 (CDC, 2009; Koh et al., 2013). The purpose of the Plain Writing Act of 2010 was to improve how federal agencies communicate to the public by producing information that is understandable and user-friendly (AHRQ, 2016). The revisions of the A.C.T. tool adhere to the guidelines in these policies, keeping the tool at a fifth-grade reading level according to SMOG and FGKL readability formulas. Currently, the idea of having multimodal forms of the A.C.T. tool, such as a printed manual, laminated one-page guide, posters for the ED, and an application for smartphones, are under consideration. In addition, printing of the tool is under consideration for use in prenatal classes.
Implications for hospital nurse educators align with the triple aim of health care to improve patient and family engagement and experience through improved HL, control costs to aid in reducing readmissions, and address population health (e.g., pediatric population) (Institute for Healthcare Improvement, 2019). An evidence-based strategy that includes teach-back can be used to facilitate professional nurse development for patient and family education (AHRQ, 2015). Nurse educators should be proficient in developing communication that promotes collaborative, intercultural, and interdisciplinary teamwork that supports health care delivery and health systems redesign using evidence-based practice (World Health Organization, 2016).
Enrollment and attendance presented a challenge for the caregiver focus group participation in this project. For those who could not attend, reasons ranged from family visiting to lack of understanding the purpose of a focus group. The inpatient caregiver focus group was representative of a diverse population and included minority participants, men and women, and parents and grandparents. In addition, the convenience sample for the expert group survey limits generalizability of the findings. More participants in every phase potentially could have strengthened the validity process and afforded more opportunity for a higher level of improvement. It is also possible that incentives for the RNs and NPs could have garnered an increased number of participants. Monetary items, such as gift cards around the holiday season for caregiver participants, may have attracted a greater number of participants as well.
Nurses are at the forefront of patient care and must be vigilant in providing patient education to the public that is understandable and actionable. Nurses are positioned to be a conduit for change for HL, patient engagement, and understanding. Evidence-based practices must be used to identify patients and caregivers with low HL, as well as low digital literacy, to guarantee everyone receives and understands the information provided to manage a child's fever.
- Agency for Healthcare Research and Quality. (2015). Use the teach-back method: Tool #5. The AHRQ health literacy universal precaution toolkit (2nd ed.). https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool5.html
- Agency for Healthcare Research and Quality. (2016). Plain language at AHRQ. https://www.ahrq.gov/policy/electronic/plain-writing/index.html
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- Alqudah, M., Johnson, M., Cowin, L. & George, A. (2014). An innovative fever management education program for parents, caregivers, and emergency nurses. Advanced Emergency Nursing Journal, 36(1), 52–61.
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- Centers for Disease Control & Prevention. (2009). Simply put: A guide for creating easy-to-understand materials. Strategic and Proactive Communication Branch, Division of Communication Services, Office of the Associate Director for Communication, Centers for Disease Control and Prevention.
- Centers for Disease Control & Prevention. (2019). What is health literacy?https://www.cdc.gov/healthliteracy/learn/index.html
- Centers for Medicare & Medicaid Services. (2012). Using readability formulas: A cautionary note. https://www.cms.gov/Outreach-and-Education/Outreach/WrittenMaterialsToolkit/Downloads/Toolkit-Part07.pdf
- Deupree, J.P., Broome, E.M. & Jukkala, A.M. (2005). Health literacy and fever management in a community based intervention. Care, 2(1), 7–25. https://www.scribd.com/document/188190310/Health-Literacy-and-Fever-Management-in-a-Community-Based-Intervention-Vol2-Iss1-1434
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- Institute for Healthcare Improvement. (2019). Initiatives: The IHI triple aim. http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx
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- Monsma, J., Richerson, J. & Sloand, E. (2015). Empowering parents for evidence-based fever management: An integrative review. Journal of the American Association of Nurse Practitioners27(4), 222–229.
- Morrison, A.K., Chanmugathas, R., Schapira, M.M., Gorelick, M.H., Hoffmann, R.G. & Brousseau, D.C. (2014). Caregiver low health literacy and nonurgent use of the pediatric emergency department for febrile illness. Academic Pediatrics, 14(5), 505–509.
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|Item No.||Item||Response Option||Rating|
| Topic: content|
| 1||The material makes its purpose completely evident||Disagree = 0, Agree = 1||1|
| 2||The material does not include information or content that distracts from its purpose||Disagree = 0, Agree = 1||1|
| Topic: word choice and style|
| 3||The material uses common, everyday language||Disagree = 0, Agree = 1||1|
| 4||Medical terms are used only to familiarize audience with the terms. When used, medical terms are defined||Disagree = 0, Agree = 1||1|
| 5||The material uses the active voice||Disagree = 0, Agree = 1||1|
| Topic: use of numbers|
| 6||Numbers appearing in the material are clear and easy to understand||Disagree = 0, Agree = 1, No numbers = N/A||0|
| 7||The material does not expect the user to perform calculations||Disagree = 0, Agree = 1||1|
| Topic: organization|
| 8||The material breaks or “chucks” information into short sections||Disagree = 0, Agree = 1, Very short b material = N/A||1|
| 9||The material's sections have informative headers||Disagree = 0, Agree = 1, Very short material = N/A||1|
| 10||The materials present information in a logical sequence||Disagree = 0, Agree = 1||1|
| 11||The materials provide a summary||Disagree = 0, Agree = 1, Very short material = N/A||0|
| Topic: layout & design|
| 12||The material uses visual cues (e.g., arrows, boxes, bullets, bold, larger font, highlighting) to draw attention to key points||Disagree = 0, Agree = 1, Video = N/A||0|
| 15||The material uses visual aids whenever they could make content more easily understood (e.g., illustration of healthy portion size)||Disagree = 0, Agree = 1||1|
| 16||The material's visual aids reinforce rather than distract from the content||Disagree = 0, Agree = 1, No visual aids = N/A||1|
| 17||The material's visual aids have clear titles or captions||Disagree = 0, Agree = 1, No visual aids = N/A||1|
| 18||The material uses illustrations and photographs that are clear and uncluttered||Disagree = 0, Agree = 1, No visual aids = NA||1|
| 19||The material uses simple tables with short and clear row and||Disagree = 0, Agree = 1,||N/A|
|column headings||No tables = NA|
|Total points: 14; Total possible points: 16 (excluding #19 N/A); Understandability score (%): 88|
| 20||The material clearly identifies at least one action the user can take||Disagree = 0, Agree = 1||1|
| 21||The material addresses the user directly when describing actions||Disagree = 0, Agree = 1||1|
| 22||The material breaks down any action into manageable, explicit steps||Disagree = 0, Agree = 1||1|
| 23||The material provides a tangible tool (e.g., menu planners, checklists) whenever it could help the user take actions||Disagree = 0, Agree = 1||1|
| 24||The material provides simple instructions or examples of how to perform calculations||Disagree = 0, Agree = 1, No calculations = N/A||1|
| 25||The material explains how to use the charts, graphs, tables, or diagrams to take actions||Disagree = 0, Agree = 1, No charts, graphs, tables, or diagrams = N/A||0|
| 26||The material uses visual aids whenever they could make it easier to act on the instructions||Disagree = 0, Agree = 1||1|
|Total points: 5; Total possible points: 7 (excluding #25 N/A); Understandability score (%): 83 (Total points/Total possible points × 100)|