Many older adults are discharged from rehabilitation hospitals after hip replacement surgery with instructions for postoperative and rehabilitation care. These instructions are complex, with many dos and don'ts that require a lengthy series of actions to be followed. Due to the complexity of these instructions, 25% to 75% of older adults return home with a limited understanding of them (Camargo, Pallin, Weiner, & Ginde, 2008; Engel et al., 2012; Flacker, Park, & Sims, 2007; Maniaci, 2008). This lack of understanding is partly due to the instructions not being created in a format that older adults with low literacy skills can read and understand (Lindquist et al., 2012; Samuels-Kalow, Stack, & Porter, 2012).
To address the issue of inadequate discharge instructions, the current approach was to add pictographs to simplified text. Pictographs are defined as “simple line drawings showing explicit healthcare actions to be taken” (Houts et al., 1998). The author developed pictograph-based discharge instructions for older adults after hip replacement surgery and validated them with nurse experts (Choi, 2011b) and older adults (Choi, 2013). The purpose of the current study was to examine the effect of pictograph-based discharge instructions on comprehension and recall of older adults with low literacy skills at 4 weeks after instructions were given.
The intervention was based on the Cognitive Theory of Multimedia Learning (CTML; Mayer, 2002, 2005), which noted that learners improve when they receive words and corresponding pictures (rather than only words) by enhancing connections between text and mental images. This improved learning is due to the human cognitive preference for picture-based, rather than text-based, information. Pictographs can also improve recall by serving as cues to help individuals remember what they read as they later view the same pictures (Houts, Doak, Doak, & Loscalzo, 2006). In addition, pictographs are well-suited to visually present step-by-step procedures of lengthy and complex discharge instructions (Choi, 2011b).
According to the 2003 National Assessment of Adult Literacy, only 3% of older adults were proficient in health literacy skills (Kutner, Greenberg, Jin, & Paulsen, 2006). The remaining older adults had low literacy (i.e., basic or below basic) skills, indicating they could read and understand only a simple appointment slip or patient education brochure, and experienced difficulty with more complex information (e.g., prescription drug labels, informed consent documents). Current health care providers have been helping by simplifying the text of discharge instruction materials. However, current efforts are far from being effective because of the way older adults with low literacy skills tend to read word-for-word, focusing exclusively on each word and accessory details rather than key concepts, thus missing many key points (Doak, Doak, Friedell, & Meade, 1998; Doak, Doak, & Root, 1996). Consequently, easy-to-read instructions may only marginally improve understanding. In addition, written text alone is not suitable for presenting complex and lengthy discharge instructions comprising multiple homecare actions. A sequence of actions can be better presented with simple line drawings (Figure).
Example pictograph-based discharge instructions on how to use a commode.
The author's pictograph-based approach was based on the CTML (Mayer, 2002, 2005). Multimedia learning occurs when learners receive information presented in more than one mode (e.g., pictures and words) because of the “multimedia effect” (Mayer, 2005, p. 47). According to the CTML, the most meaningful and successful learning occurs when learners construct and coordinate multiple representations of the same material, including words and pictures. With text alone, learners try to form their own mental images and connect them to the words. However, this process may be difficult for adults with declined cognitive and/or literacy capabilities. To assist such older adults, appropriate visual aids (e.g., pictographs) can be used to supplement written instructions.
Visual aids have been used in educational health care instructions in the format of patient information leaflets (e.g., medication instructions, treatment of dehydration, diet regimen instructions) (Kim, Nakamura, & Zeng-Treitler, 2009; Leiner, Handal, & Williams, 2004; Townsend, Sylva, Martin, Metz, & Wooten-Swanson, 2008) or medicine labels (Dowse & Ehlers, 2005; Kripalani et al., 2007). For example, a few studies developed pictographs to represent a series of health care actions to manage cancer- and AIDS-related symptoms (Houts et al., 1998; Houts, Witmer, Egeth, Loscalzo, & Zabora, 2001) and to increase fruit and vegetable consumption among older adults with low literacy skills (Houts et al., 2006). Pictograph instructions significantly improved short-term (i.e., immediately after instruction) and long-term (4 weeks after instruction) recall (Houts et al., 1998, 2001). However, these studies targeted community-dwelling adults (Houts et al., 2001, 2006) or college students (Houts et al., 1998) with hypothesized health care scenarios. Further research is needed to examine older adults' health care discharge instructions in actual health care settings. The fact that only a few studies have examined pictograph-based discharge education (and integrated into rehabilitation) in health care settings illustrates the significance of exploring this new approach. Details about pictographs used in health care settings can be found in a review study by the author (Choi, 2011a).
The author previously developed pictographs with relevant captions for older adults after hip replacement surgery. Discharge instructions included an overview of total hip replacement surgery, advice for home care, signs/symptoms of complications, instructions for prescribed medications, and guidance on when to seek medical help. Nurse experts evaluated the pictographs and text for appropriateness, accuracy, and relevance, and acceptability and comprehension with older adults with low literacy skills. The expert evaluation showed that pictographs using stick figures were well-suited for presenting action-based discharge instructions (Choi, 2011b). Older adults also perceived that the drawings were engaging and easy to understand, and enhanced the clarity of the intended health care messages (Choi, 2013).
Participants were recruited from a rehabilitation hospital that is part of an acute care community hospital and provides intensive, multidisciplinary rehabilitation treatments in western Massachusetts. The hospital serves large populations of underserved, low-education patients. A convenience sample of 42 older adults undergoing postsurgical hip replacement care participated in the study. Inclusion criteria were age 65 or older, inadequate or marginal health literacy (i.e., scoring ≤22 on the short version of the 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 (as determined by self-report) and demonstrated overt delirium, dementia, or any condition indicating deteriorating cognitive status as determined by the Mini-Cog (Borson, Scanlan, Brush, Vitaliano, & Dokmak, 2000).
A posttest-only comparison group design was used to compare pictograph-based (intervention group, n = 21) to text-only (comparison group, n = 21) discharge instructions. Participants were randomly assigned to the intervention or comparison group using SPSS-generated (version 22) random numbers. Data collection occurred 4 weeks after discharge instruction education. Data collection time was selected based on the findings of Canale and Beatty (2007) that the first 4 weeks after discharge is a critical period for preventing complications and improving functional recovery.
Health literacy in older adults was measured by the S-TOFHLA (Baker et al., 1999). The scale has two sections: reading (36 items) and quantitative (numeracy, 4 items) comprehension. The S-TOFHLA has been successfully used with community-dwelling and outpatient older adults (Baker et al., 1999; Campbell, Edwards, Ward, & Weatherby, 2007; Donelle, Hoffman-Goetz, & Arocha, 2007), and had acceptable internal consistency reliability (Cronbach's alpha = 0.76) in the current study. Cognitive impairment was assessed by Mini-Cog scores of less than 3 (Borson et al., 2000). The Mini-Cog combines clock drawing and three-word recall tests, and has a high level of sensitivity (76%) and specificity (89%) (Borson, Scanlan, Chen, & Ganguli, 2003). The Mini-Cog is not adversely influenced by age, language, and education, making it a valid tool for older adults with low literacy skills and education levels (Borson et al., 2000).
Comprehension and recall were measured by a 20-item survey the author developed. Each item was scored with 1 for a correct answer and 0 for a wrong answer. Total scores ranged from 0 to 20 and higher total scores indicated greater comprehension and recall. The survey corresponded to four sections of the discharge instructions: (a) diagnosis and treatments, (b) medication, (c) warning signs and symptoms, and (d) homecare activity advice.
Comprehension, which involves interpreting the meaning of words or pictures to understand their collective meaning, is different from recall, which involves retrieving individual words or picture elements from memory (Houts et al., 2006). To address this difference, each question was broken into two parts. First, participants were asked to recall information from the discharge instructions (e.g., “What did the nurse tell you about when using a toilet seat for the first couple of weeks after surgery?”). Second, they were asked to explain or do something with the previous information (e.g., “How high or low should the toilet seat be?”). The comprehension/recall questionnaire had acceptable internal consistency reliability (Cronbach's alpha = 0.76).
After study approval from the institutional review boards at the university and participating hospital, potential participants (who were referred by a nurse manager in the hospital) were invited to participate. After written informed consent was obtained, participants were screened for inclusion and exclusion criteria, and randomly assigned to the intervention or comparison group.
One or two days before discharge, participants in the intervention group received pictograph-based discharge instructions in a 60-minute, one-on-one teaching session in the family interview room. To ensure that the effect of caregiving reinforcement was as uniform as possible, family caregivers joined patients in the education session. To uniformly present the instructions, the author prepared a package including instructions about the interview, definitions of pictographs, an explanation of standardized conventions for meanings in pictographs (e.g., a red lightning bolt indicates pain), and the demographic questionnaire. The author led the discharge education session and presented each of the five sections, followed by a brief discussion that encouraged participants to contribute. At the end of the session, each participant was given a pictograph-based discharge instruction booklet. The comparison group received one-page, text-only discharge instructions currently offered to patients at the hospital. At 4 weeks after discharge instructions were given, a research assistant collected data in face-to-face interviews at participants' homes. Prior to data collection, the research assistant was trained by the author to correctly administer the comprehension and recall questionnaire; data collection was monitored through regular meetings with the author.
A group difference (intervention versus comparison) in comprehension and recall was tested by an independent t test. Demographic variables (i.e., age, gender, and race) were summarized as means and standard deviations for continuous variables, and as frequency and percentage for categorical variables. To assess whether group differences existed, demographic and health literacy assessment variables were analyzed using an independent t test for age, and the S-TOFHLA and chi-square test for gender and race. All analyses were performed using IBM SPSS Statistics 22.
Characteristics of Participants
Forty-two older adults participated in the current study. Participants were mostly female (66.7%, n = 28) and had a mean age of 67.59 years (SD = 5.41, range = 65 to 76 years) and a high school degree or lower in education (83.3%, n = 35). Participants were racially diverse: 69% (n = 29) White, 11.9% (n = 5) African American, 4.8% (n = 2) Hispanic, and 2.4% (n = 1) Asian/Pacific Islander. No participants screened positive for cognitive impairment measured by the Mini-Cog. Participants' mean S-TOFHLA score was 17.02 (SD = 5.16), indicating marginal or inadequate health literacy.
The intervention and comparison groups were equivalent in baseline demographic characteristics. No significant differences were found between group demographics (t = −0.82, p = 0.42 for age; χ2 = 0.05, p = 0.82 for gender; and χ2 = 7.40, p = 0.06 for race) and health literacy (t = 1.36, p = 0.18), indicating random assignment was successful in equating the two groups. Table 1 shows a summary of demographic variables and S-TOFHLA scores.
Demographic Variables and S-TOFHLA Scores
Comparison of Comprehension and Recall
Significantly greater improvements in scores for comprehension and recall were demonstrated by the intervention group rather than the comparison group (Table 2).
Comparison of Comprehension and Recall in the Intervention and Comparison Groups
The findings of the current study indicated that pictograph-based discharge instructions were effective in improving comprehension and recall of discharge instructions for older adults with low literacy skills, and expanded on the effectiveness of pictographs shown to community residents in hypothesized scenarios (Houts et al., 2001) compared to actual health care practice (for which instructions are lengthy and complicated). The findings also emphasized the effectiveness of a pictograph-based approach, as well as strengthened its clinical applicability, for patients who have low literacy skills in rehabilitation health care practice.
Future studies are necessary to replicate the study findings with larger and more diverse samples in acute, sub-acute, and outpatient settings. A follow-up study is necessary to examine adherence to discharge instructions, emergency department admission/hospital readmission, and complications (e.g., dislocation of the hip replacement, infection in the incision, blood clots in legs). Previous health care education studies have evaluated patients' comprehension or recall of health care instructions, but not adherence to instructions and health outcomes (Choi, 2011a; Houts et al., 2006; Katz, Kripalani, & Weiss, 2006). Linking the effect of pictograph-based discharge instructions to patients' health outcomes is an important first step in the translational research effort (Grady, 2010). Translating research into evidence-based nursing practice and evaluating effectiveness of the implementation in terms of patient outcomes are necessary for advancing excellence in health care quality (Grady, 2010; Woods & Magyary, 2010).
The current study tested only short-term effects (i.e., 4 weeks after discharge). However, a full recovery after hip replacement surgery usually takes 2 months, thus it is necessary to test the long-term effects (e.g., 8 weeks) of pictograph-based instructions to ensure the effect sustains a full recovery period. Research has also shown that pictures enhance short-term effects (Houts et al., 2001), but long-term effects have not been examined. Future studies should examine the long-term effects of pictograph-based discharge instructions.
Several limitations need to be considered when interpreting the results of the current study. Generalizability of the findings is limited because of the pilot nature of the study; convenience sampling was used and the study was conducted in one geographical setting. In addition, the comprehension and recall survey was developed by the author; therefore, instrument reliability and validity may be threatened. However, the survey was validated by five orthopedic nurse experts and showed good internal consistency reliability, minimizing the threat.
Pictograph-based instructions are effective in improving comprehension and recall of older adults with low literacy skills after hip replacement surgery, illustrating the significance of this approach in rehabilitation care settings. Future research is suggested to further examine the effect of pictographs on desired behavior changes (i.e., adherence to discharge instructions) and improved health outcomes (e.g., decreased emergency department admission/hospital readmission, complications).
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Demographic Variables and S-TOFHLA Scores
|Variable||Intervention Group (n = 21), n (%)||Comparison Group (n = 21), n (%)||Total (N = 42), n (%)|
| Female||14 (66.7)||14 (66.7)||28 (66.7)|
| Male||6 (28.6)||7 (33.3)||13 (31)|
| Missing||1 (4.7)||0 (0)||1 (2.4)|
| White||10 (47.6)||19 (90.5)||29 (69)|
| African American||4 (19)||1 (4.8)||5 (11.9)|
| Asian/Pacific Islander||1 (4.8)||0 (0)||1 (2.4)|
| Hispanic||1 (4.8)||1 (4.8)||2 (4.8)|
| Missing||5 (23.8)||0 (0)||5 (11.9)|
| High school or lower||16 (76.2)||19 (90.5)||35 (83.3)|
| College||2 (9.5)||2 (9.5)||4 (9.5)|
| Missing||3 (14.3)||0 (0)||3 (7.1)|
|Age (years) (mean, SD)||68.3 (6.28)||66.9 (4.49)||67.59 (5.41)|
|S-TOFHLA score (mean, SD)a||15.95 (1.43)||18.1 (7.09)||17.02 (5.16)|
Comparison of Comprehension and Recall in the Intervention and Comparison Groups
|Variable||Intervention Group, Mean (SD)||Comparison Group, Mean (SD)||Independent t Test, p Value|
|Comprehension||7.78 (1.73)||6.42 (1.87)||t (df = 35) = −2.29, 0.02|
|Recall||7.94 (1.70)||6.47 (2.25)||t (df = 35) = −2.24, 0.03|