Journal of Gerontological Nursing

Feature Article 

Older Adults’ Perceptions of Pictograph-Based Discharge Instructions after Hip Replacement Surgery

Jeungok Choi, PhD, MSN, MPH, RN

Abstract

Current text-based discharge instructions are unsuitable for low-literate older adults who have difficulty following written action-based instructions. To address this issue, we developed discharge instructions for low-literate older adults after hip replacement surgery using pictographs (i.e., simple line drawings with stick figures showing explicit care actions). The aim of this focus group study was to examine the acceptability and comprehension of these instructions to 15 low-literate older adults. Participants perceived that the pictograph-based discharge instructions helped them understand the intended health care messages, especially for step-by-step procedures of discharge actions. The black-and-white line drawings were well received by all participants of various race/ethnicity. A pictograph-based approach is an effective strategy for developing discharge instructions not only for patients with low literacy skills in acute health care settings, but also for immigrants with significant communication challenges. Future research is suggested to compare the effects of pictograph-based and text-based instructions on adherence to instructions and health outcomes. [Journal of Gerontological Nursing, 39(7), 48–54.]

Dr. Choi is Assistant Professor, School of Nursing, University of Massachusetts, Amherst, Amherst, Massachusetts.

The author has disclosed no potential conflicts of interest, financial or otherwise. This project was partially supported by the Faculty Research Grant/Healey Endowment Grant, University of Massachusetts, Amherst. The author thanks Willow Cohen for assisting data collection and Michael Salyh for drawing the pictographs.

Address correspondence to Jeungok Choi, PhD, MSN, MPH, RN, Assistant Professor, University of Massachusetts, Amherst, School of Nursing, 120 Skinner Hall, 651 North Pleasant Street, Amherst, MA 01003; e-mail: jeungokc@nursing.umass.edu.

Received: July 17, 2012
Accepted: September 19, 2012
Posted Online: April 26, 2013

Abstract

Current text-based discharge instructions are unsuitable for low-literate older adults who have difficulty following written action-based instructions. To address this issue, we developed discharge instructions for low-literate older adults after hip replacement surgery using pictographs (i.e., simple line drawings with stick figures showing explicit care actions). The aim of this focus group study was to examine the acceptability and comprehension of these instructions to 15 low-literate older adults. Participants perceived that the pictograph-based discharge instructions helped them understand the intended health care messages, especially for step-by-step procedures of discharge actions. The black-and-white line drawings were well received by all participants of various race/ethnicity. A pictograph-based approach is an effective strategy for developing discharge instructions not only for patients with low literacy skills in acute health care settings, but also for immigrants with significant communication challenges. Future research is suggested to compare the effects of pictograph-based and text-based instructions on adherence to instructions and health outcomes. [Journal of Gerontological Nursing, 39(7), 48–54.]

Dr. Choi is Assistant Professor, School of Nursing, University of Massachusetts, Amherst, Amherst, Massachusetts.

The author has disclosed no potential conflicts of interest, financial or otherwise. This project was partially supported by the Faculty Research Grant/Healey Endowment Grant, University of Massachusetts, Amherst. The author thanks Willow Cohen for assisting data collection and Michael Salyh for drawing the pictographs.

Address correspondence to Jeungok Choi, PhD, MSN, MPH, RN, Assistant Professor, University of Massachusetts, Amherst, School of Nursing, 120 Skinner Hall, 651 North Pleasant Street, Amherst, MA 01003; e-mail: jeungokc@nursing.umass.edu.

Received: July 17, 2012
Accepted: September 19, 2012
Posted Online: April 26, 2013

Discharge instructions for hip replacement surgery essentially consist of recommended homecare actions, such as “dos” (e.g., use pillows between your legs when sleeping on your back or on your healthy side) and “don’ts” (e.g., do not twist your back). However, these health care actions are currently provided in text-based instructions, which are often difficult for patients to follow precisely at home. These instructions are especially difficult to understand for older adults with low-literacy skills (i.e., sixth-grade or lower reading level) because written text alone is not suitable for presenting lengthy, complex discharge instructions with multiple actions. The current approach to dealing with low literacy is to use easy-to-read instructions with simplified language. This approach only marginally helps low-literate adults’ understanding because they focus exclusively on each word and accessory details rather than the key concepts; they “plow” the text line by line, giving a narrow field of view and missing many key points, resulting in their skipping over large amounts of information (Doak, Doak, Friedell, & Meade, 1998  ; Doak, Doak, & Root, 1996  ).

To address this issue, low-literacy pictograph-based discharge instructions were developed for older adults after hip replacement surgery and validated with experts in hip replacement care of older adults (Choi, 2011b  ). Pictographs (simple line drawings showing explicit discharge care actions) can show step-by-step procedures for lengthy and complex discharge actions, make an entire action sequence easier to learn, direct attention to important details, and reduce reliance on complex textual information. Figure shows an example of pictographs presenting step-by-step procedures of “getting out of chairs.” Our approach to pictographs is based on the cognitive theory of multimedia learning, which proposes that appropriate visuals facilitate the cognitive learning process of storing information, stimulating retrieval of that information, and reconstructing information through visual associations (Mayer, 2001  ).

 
Example of pictographs to show discharge instructions for “getting out of chairs.” 

Figure 1. Example of pictographs to show discharge instructions for “getting out of chairs.”

Older adults with low literacy skills do not share the same logic, language, and experiences as health care professionals (Doak et al., 1996  ). Thus, discharge instructions developed by health care professionals often have mismatches and gaps in the logic that may lead to patients’ misunderstanding, disbelief, and rejection of discharge instructions. To maximize the relevance and clarity of pictograph-based discharge instructions, these instructions should be tested with their target population for suitability of design, format features, and content (Doak et al., 1996  ; Dowse & Ehlers, 2001  ; Houts, Doak, Doak, & Loscalzo, 2006  ; Ngoh & Shepherd, 1997  ; Roter, Rudd, Keogh, & Robinson, 2006  ). Indeed, developing and validating pictographs in close consultation with individuals in the target population was shown to ensure that the pictographs were relevant and meaningful for users (Dowse & Ehlers, 2001  ; Ngoh & Shepherd, 1997  ; Roter et al., 2006  ). Thus, in the current focus group study we examined older adults’ acceptance and comprehension of the pictograph-based discharge instructions. The purpose of this article is to report the findings of focus group interviews with 15 low-literate older adults after hip replacement surgery.

Pictographs in Health Care Education

Pictographs have been used in health care instructions as patient information leaflets (e.g., preparing and administering treatment for dehydration, medication instructions, diet regimen instructions) (Dowse & Ehlers, 2005  ; Houts et al., 1998  ; Houts, Shankar, Klassen, & Robinson, 2006  ; Houts, Witmer, Egeth, Loscalzo, & Zabora, 2001  ; Kim, Nakamura, & Zeng-Treitler, 2009  ; Kripalani et al., 2007  ; Leiner, Handal, & Williams, 2004  ; Townsend, Sylva, Martin, Metz, & Wooten-Swanson, 2008  ; Wolff et al., 2009  ) and were found to be especially effective in communicating with older adults with low-literacy skills (Austin, Matlack, Dunn, Kesler, & Brown, 1995  ; Dowse & Ehlers, 2001, 2005  ; Houts et al., 2001  ; Kripalani et al., 2007  ; Leiner et al., 2004  ; Mansoor & Dowse, 2003  ). For example, to depict a patient’s daily medication regimen, “a pill card” was developed using pill images and icons (Kripalani et al., 2007  ). Patients with inadequate to marginal literacy skills or cognitive impairment were more likely to initially refer to the card on a regular basis, and by 3 months, 92% of pill card users rated the card as very easy to understand, and 94% found it helpful for remembering important medication information, such as the name, purpose, or time of administration (Kripalani et al., 2007  ).

Houts and colleagues developed pictographs to represent a series of health care actions to manage cancer- and AIDS-related symptoms (Houts et al., 1998, 2001  ) and to increase fruit and vegetable consumption among older adults with low-literacy skills (Houts, Shankar, et al., 2006  ). Instructions were represented as a sequence of actions; for example, “rinse the mouth with baking soda after eating” was shown as two pictographs: eating meals and mouth rinsing (Houts et al., 1998  ). These pictograph instructions significantly improved short-term recall immediately after instructions and long-term recall 4 weeks after instructions (Houts et al., 1998, 2001  ).

This review reveals that pictograph-based instructions in health care settings bear promise for improving discharge education for older adults with low-literacy skills. However, these studies have some shortcomings. First, most studies generally used pictographs to represent static objects or concepts associated with health care actions (i.e., taking body temperature is a drawing of thermometer) rather than representing health care actions themselves (i.e., drawing of a nurse taking body temperature) (Dowse & Ehlers, 2005  ; Kripalani et al., 2007  ; Mansoor & Dowse, 2003  ; Wolff et al., 2009  ). Thus, older adults may not accurately follow the intended health care actions. Second, the studies addressed only medication instructions (e.g., drawings presenting the day and time to take and dose of medications) (Dowse & Ehlers, 2005  ; Kripalani et al., 2007  ; Mansoor & Dowse, 2003  ; Ngoh & Shepherd, 1997  ). Third, some studies targeted community-dwelling adults (Houts et al., 2001  ; Houts, Shankar, et al., 2006  ) or college students (Houts et al., 1998  ) using “hypothesized health care scenarios” (e.g., simulated instructions of how to manage illness-related symptoms and problems [Houts et al., 2001  ]). Thus, the findings do not clearly portray patients’ experience in an actual health care practice. The review by Choi (2011a  ) contains more details of the literature on using pictographs in health care.

To address the issues identified above, low-literacy, pictograph-based discharge instructions for older adults after hip replacement surgery were developed and validated with five nurse experts who had at least 5 years of experience in patient care after hip replacement surgery and/or care of older adults (Choi, 2011b  ). The experts evaluated the pictographs using stick figures as well suited for presenting action-based discharge instructions, easy to understand, and enhancing the clarity of the intended health care messages (Choi, 2011b  ). As a next step, the experts recommended testing the instructions with the end users. Thus, this article reports the findings of a focus group study with 15 low-literate older adults after hip replacement surgery to examine their comprehension and acceptance of the pictograph-based discharge instructions.

Method

Participants

A convenience sample of 15 low-literate older adults after hip replacement surgery was recruited from one community hospital in western Massachusetts. Potential participants were referred by a nurse coordinator in the hospital or contact calls from the patients after seeing the flyers posted on the communication board on the orthopedic units. Inclusion criteria were: age ⩾65; having marginal or inadequate health literacy (scoring ⩽22 on the Short Test of Functional Health Literacy in Adults (S-TOFHLA, Baker, Williams, Parker, Gazmararian, & Nurss, 1999  ); and able to communicate in English. Patients were excluded if they had visual acuity worse than 20/60 with glasses or demonstrated overt delirium, dementia, or any condition indicating deteriorating cognitive status as determined by the Mini-Cog (Borson, Scanlan, Brush, Vitaliano, & Dokmak, 2000  ).

Measures

Health literacy was measured by the 40-item S-TOFHLA (Baker et al., 1999  ), which has two sections: reading comprehension (36 items) and quantitative comprehension (numeracy, 4 items). The S-TOFHLA has been successfully used in community-dwelling and outpatient older adults with good internal consistency reliability (0.70 to 0.97) (Baker et al., 1999  ; Campbell, Edwards, Ward, & Weatherby, 2007  ; Donelle, Hoffman-Goetz, & Arocha, 2007  ). Cognitive impairment was measured by the Mini-Cog (Borson et al., 2000  ), which combines the clock drawing test and three-word recall and has a high level of sensitivity (76%) and specificity (89%) (Borson, Scanlan, Chen, & Ganguli, 2003  ). Unlike the Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975  ), the Mini-Cog is not adversely influenced by age, language, and education (Borson, Scanlan, Watanabe, Tu, & Lessig, 2005  ).

Procedures

Once the study was approved by the institutional review boards at the University and the participating hospital, eligible patients and those who signed informed consent were invited to participate. After participants were discharged home, they were contacted for scheduling interview sessions. The focus group interviews took place in community rooms in the public libraries or in the town halls nearby participants’ home. Participants were screened for inclusion and exclusion criteria using the S-TOFHLA and the Mini-Cog. Interviews were scheduled in five groups with 3 or 4 participants. The interviews began after the author provided verbal instructions. To ensure that the instructions were uniformly presented to all participants, the author prepared a written package to guide interview sessions. The package contained information about the purpose of the interview, what pictographs are, explanations of standardized conventions for meanings in pictographs (i.e., a red lightning bolt indicates pain). Next, participants read the 19-page pictograph-based instruction booklet, which includes 45 pictographs with simplified text, and then the author asked them to identify if the materials were clear and understandable, responsive to their needs and concerns, and acceptable. During the interviews, participants were encouraged to “think aloud” (to verbalize what they were thinking) (van Someren, Barnard, & Sandberg, 1994  ) to help active participations by all group members. The author constantly reminded them to say out loud what came to their mind when participants were reluctant to speak or they were silent during the interviews. Participants’ comments were documented by a research assistant (RA) in a Microsoft Word® file. Each interview took approximately 40 to 50 minutes.

Data Analysis

To develop coding categories, the author and the RA read through the printed Word file, taking notes on topics discussed in the interviews. The author and the RA then compared and revised the categories individually arrived at and determined final coding categories. This list of categories was then reviewed and refined further by combining or removing repetitious or similar topics. Using highlighter pens, a different color was assigned to each category (Burns & Grove, 2008  ).

Results

Demographics of the Sample

Participants were mostly women (82.4%), had a mean age of 68.2 (SD = 4.73 years), and had a high school or equivalent diploma (80%). Participants were racially diverse (73.3% Caucasian, 13.3% Hispanic, 6.7% African American, and 6.7% Asian/Pacific Islander). No participants were screened positive for cognitive impairment measured by the Mini-Cog. Participants’ mean S-TOFHLA score was 19.47 (SD = 3.95), indicating marginal or inadequate health literacy.

Focus Group Interview Findings

Overall, participants perceived the pictograph-based discharge instructions as engaging (i.e., simple line drawings with brief captions helped them understand the intended health care messages, especially for instructions that required a step-by-step procedure such as “getting out of a chair”). The black-and-white simple line drawings were well received by all participants regardless of race/ethnicity. They perceived the language as simple and clear and the drawings as self-explanatory. They appreciated the captions accompanying the drawings; the captions clarified the drawings’ intended health care messages.

The participants made 76 comments on the negative aspects of pictographs and suggestions for improvement. Seven key topics emerged from those 76 comments/suggestions:

  • Compare and comparison of instructions.
  • Use of cues.
  • One message per one pictograph.
  • Consistency in accessory details.
  • Use of simple and specific terms.
  • Detailed and specific backgrounds and accessory details.
  • Use of inserts or callouts to add more details or complementary information.

First, pictographs showing dos and don’ts need to be side-by-side, so patients can clearly compare and contrast what they should and should not do. However, don’ts should be emphasized more than dos using red X marks or “NO.” Second, the key points in each drawing should be emphasized using cues such as arrows, colored type, or capital letters, to help direct patients’ attention to key messages. Third, each instruction should deliver only one message, presented in one pictograph. For example, “Do not cross your legs or ankles” should be presented as two instructions and two separate pictographs: one drawing showing a person crossing their legs at the knees and another drawing showing legs crossed at the ankles with red X marks on each drawing. Fourth, the drawings should be consistent in terms of background or accessory details. For example, participants pointed out that some drawings used different style chairs (e.g., sofas, stools, recliners); the style should be the same throughout the instructions. Fifth, instructions could be clarified by using more specific and simple terms. For example, rather than “Do not wear open-toe shoes,” the participants could grasp the message more quickly if the instruction was “Do not wear flip flops or sandals.” Sixth, the pictograph background and accessory details not directly associated with the intended messages should be specific and detailed enough to support the key messages. For example, in the instruction, “Show ALL your medication bottles to your nurse,” medication bottles in a medicine cabinet should have “Rx” on them to indicate that they are medications. Another example was that the instruction to use a chair in the shower should show safety grab bars on the shower wall. Lastly, several instructions did not accurately deliver the intended messages with stick figures. For example, participants did not grasp the message of “Sleep on your side with unoperated side up” because simple line drawings using stick figures could not clearly differentiate among positions of lying on the back, stomach, or side. Participants suggested using inserts or callouts to clarify the instructions by adding more details or complementary information (Figure ). All of these comments and suggestions were incorporated into the final version of discharge instructions.

 
An example of using inserts in pictographs to show discharge instructions for “sleeping on your side.” 

Figure 2. An example of using inserts in pictographs to show discharge instructions for “sleeping on your side.”

Discussion

Older adults perceived that pictograph-based discharge instructions helped them understand the intended health care messages, especially for topics that required step-by-step procedures. Simple line drawings using stick figures were well received by all participants with various race/ethnicity. The findings highlight several issues or problems regarding the use of pictographs for older adults with low-literacy skills. First, participants focused on accessory details or background as well as on key messages such as medication bottles having “Rx” on them or grab bars on a shower wall. These findings are consistent with a report that low-literate people focus exclusively on accessory details in drawings when they read health care instructions (Doak et al., 1996  ). Taken together, these findings emphasize that health care educators developing care instructions for older adults with low-literacy skills should pay particular attention to accessory details or background to ensure that they are accurate and support or complement key messages.

The second issue is that both the correct and incorrect actions should be placed side by side (e.g., sitting in a chair with legs crossed and sitting with legs apart), so patients can compare and contrast clearly what they should and should not do, thus avoiding confusion and stressing the intended message. However, participants focused more on instructions showing don’ts rather than dos, and wanted to emphasize don’ts by including “NO” or red “X” marks. This finding is interesting because when nurse experts evaluated the same pictograph-based instructions, they suggested emphasizing dos rather than don’ts (Choi, 2011b  ). These findings show a clear mismatch between health care professionals’ and patients’ focus when reading health care instructions. Previous studies have reported similar findings: There are discrepancies in discharge communications with regard to what information may be important for the nurse to give and what information may be important for the patient to receive (Bobay, Jerofke, Weiss, & Yakusheva, 2010  ; Maloney & Weiss, 2008  ). These findings together with this study finding emphasize the importance of pilot testing health care educational materials with the intended target population.

The third issue is about supplementing pictographs with inserts or callouts. Although participants perceived that pictograph-based instructions were clear and easy to understand and that pictographs were self-explanatory, a few instructions did not clearly deliver the intended message because stick figures could not represent volumes associated with body shape. For example, showing a wound on the hip of a line drawing was challenging. As participants suggested, using inserts or callouts could add more details to stick figures and emphasize only the key message. Thus, patients can easily and quickly grasp more specifics about key messages without being distracted by unnecessary details. Using inserts or callouts could be a strategy to reinforce pictograph-based instructions when discharge instructions need to show body-shape volumes.

The one common message from all participants was to use cues. Participants preferred various formats of cueing such as arrows, circling, magnifying the text or drawings, or adding a splash of color. This finding is consistent with a previous study on discharge instructions for older adults with low-literacy skills (Choi, 2011b  ), which found that participants preferred cueing to direct their attention to key messages in the drawings. These findings echo the suggestion that cueing could draw low-literate older adults’ attention to key points to remedy their tendency to “plow” the text and to pay attention to accessory details (Doak et al., 1996  ).

Although the study participants perceived the pictograph-based discharge instructions as useful and easy to understand, this study did not compare patients’ responses to pictograph-based and text-based discharge instructions. Future studies should directly compare these types of discharge instructions on patients’ comprehension, recall, adherence to discharge instructions, and health outcomes. Previous health care education studies have evaluated patients’ comprehension or recall of health care instructions but not adherence to instructions and health outcomes (Houts, Doak, et al., 2006  ; Katz, Kripalani, & Weiss, 2006  ). Thus, patients’ comprehension or recall of health care instructions has not yet been clearly linked to desired behavior change (adherence) and improved health outcomes. Future research is suggested to compare the effects of pictograph-based instructions and text-based instructions on patients’ adherence to instructions and health outcomes, as well as comprehension and recall.

Lastly, the results would provide a model for developing pictograph-based health care instructions for immigrants who speak English as a second language and present significant communication challenges for health care providers. As a universal language to communicate with people speaking different languages, pictographs can be an efficient tool to improve health care education for this underserved population. Specifically, pictographs using stick figures are culturally and language-neutral, whereas other formats of visual aids (e.g., photographs, animations, video clips) can show only one type of person (e.g., one gender, culture, race/ethnicity), often leading patients from different backgrounds to feel “that’s not like me” (Choi & Bakken, 2010  ). Use of simple line drawings with stick figures would enhance patients’ active participation in their health care learning because the drawings are equally appropriate for different ethnicities, languages, ages, and genders (Dowse & Ehlers, 2001  ; Houts et al., 2001, 2006  ).

This study has several limitations. Participants were recruited from one community hospital; therefore, sample representativeness may be limited. Additionally, differences may exist between those who agreed to participate in the focus group interviews and those who declined; however, the results are not likely to reflect the perceptions and experiences of those who did not participate.

Conclusion and Nursing Implications

Older adults with low-literacy skills in this study perceived that pictograph-based discharge instructions after hip replacement surgery helped them understand the intended health care messages. The black-and-white line drawings were well received by all participants of various race/ethnicity who perceived the pictographs as easy to understand and very engaging.

Improving discharge education for older low-literate adults may improve their health outcomes by lowering complication rates and avoiding unnecessary health care costs. A pictograph-based discharge instructions booklet is an effective tool for nurses to educate these older adults. The pictograph-based approach described here involves professionally drawn pictures; however, nurses can easily adapt it in health care settings where professional illustrators are not available. With a brief instruction of concepts of pictographs and how to draw stick figures, nurses can use hand-drawn pictographs to illustrate the intended health care instructions without difficulty.

This approach might be used to develop health care instructions for immigrants with communication challenges. Using pictograph-based health care instructions may be more practical than having interpreters or pre-translated health care materials available in health care settings. However, further testing of effects of pictographs in an immigrant population are needed before this approach is used.

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Keypoints

Choi, J. (2013). Older Adults’ Perceptions of Pictograph-Based Discharge Instructions after Hip Replacement Surgery. Journal of Gerontological Nursing, 39(7), 48–54.

  1. Current text-based discharge instructions are unsuitable for low-literate older adults who have difficulty following written action-based instructions.

  2. In this study, a discharge instruction booklet was developed for older adults after hip replacement surgery using pictographs (i.e., simple line drawings showing explicit discharge-care action) and examined the acceptability and comprehension of these instructions to 15 low-literate older adults.

  3. Study findings show that the pictograph-based discharge instructions helped older adults understand the intended health care messages, especially for step-by-step procedures of discharge actions, and the black-and-white line drawings were well received by all participants of various race/ethnicity.

  4. A pictograph-based approach is an effective strategy for developing discharge instructions for patients with low-literacy skills in acute health care settings.

 

10.3928/00989134-20130415-02

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