Patient education materials (PEM) that highlight the risk factors, signs, symptoms, and treatment options for age-related hearing loss (ARHL) are critical given that the number of people with hearing loss is rapidly increasing due to population aging. When designing PEMs, it is important to consider the health literacy skills of the intended audience to ensure that the materials can be read, used, and understood by consumers. Health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”1 If health care providers share educational materials that are not matched to the health literacy skills of their patients, these materials will be ineffective at encouraging individuals to seek hearing health care and will not support the development of self-efficacy and self-management skills. In the United States, the average adult reads at the eight- or ninth-grade level,2 and only an estimated 12 percent of adults can effectively read and understand health information.3 Readability and suitability are common measures used to assess the health literacy of written PEMs. Readability is an objective measure of how easy or difficult a text is to read, while suitability measures design appropriateness and evaluates the adequacy of material content and design, cultural and linguistic appropriateness, and ability to motivate individuals to take action.4
Previous investigations into the readability and suitability of PEMs on hearing health have revealed that the majority of materials are not written at an appropriate level for the intended audience.5-8 These studies have focused on the readability and suitability of PEMs on general hearing health topics; however, the issue of health literacy is particularly relevant to older adults who demonstrate lower levels of health literacy compared with their younger counterparts.
We recently explored the readability and suitability of PEMs on topics specifically related to ARHL.9 PEMs were sampled from electronic health record (EHR) systems based on the rationale that these resources are likely to be dispensed by trusted health care providers. While the inclusion of PEMs in EHR databases allows for quick dispensation of PEMs at point of care, practitioners may share these resources without carefully considering whether the health literacy demands are appropriate for their patients. PEMs were also obtained from communication sciences and disorders (CSD) organizations based on the rationale that these materials are likely to emerge in search results when people go online to learn more about hearing health care. The sample included 27 PEMs from select sources and focused exclusively on ARHL diagnosis, management, and treatment, hearing loss prevention, and communication strategies for affected individuals and their families. Readability was assessed using three formulas (i.e., Flesch-Kincaid Index10,11 and Simple Measure of Gobbledygook [SMOG,]12 and suitability was assessed using the Suitability Assessment of Materials [SAM]4). The SAM is used to score PEMs on 22 factors categorized into the following six domains: content, literacy demand, graphics, layout and typography, learning stimulation and motivation, and cultural appropriateness. SAM scores from the 22 factors were combined to generate an overall percentage score, which was then used to classify PEMs as not suitable, adequate, or superior based on the number of features that support usability. The SAM can help determine which area(s) of PEMs would benefit from modification to improve design appropriateness, comprehensibility, and usability.
Our study revealed that 66.7 percent of PEMs were written above target readability (i.e., above eighth-grade level), which was based on the average reading level of U.S. adults. The average readability of all PEMs in the study was grade level 9.73, indicating that an individual would need an education level higher than ninth grade to be able to read the material. An analysis of suitability using the SAM revealed that the average PEM was classified as adequate. In total, 85.2 percent (23/27) of PEMs were classified as adequate, and 14.8 percent (4/27) were classified as not suitable. No PEMs were identified as having superior suitability.
The areas of strength among the selected PEMs included having an explicit statement of purpose, maintaining a scope that was limited to essential information, and using advanced organizers. In contrast, the areas of weakness included a lack of summary of key information, high reading grade level, failure to use reader-friendly vocabulary, and limited subdivision of complex topics. We found that the majority of PEMs failed to summarize key information, which is an important component that helps readers identify and review the most important information. The literacy demands of the majority of PEMs exceeded the reading abilities of the average U.S. adult, and most of them used field-specific jargon and vocabulary terms that would likely be unfamiliar to readers without prior knowledge of hearing health. The majority of PEMs on ARHL provided a great deal of complex information under a single heading, which is problematic because this may overwhelm readers and reduce their self-efficacy beliefs about their ability to obtain hearing health care and manage life with hearing loss. It would be beneficial to subdivide complex topics into smaller subcomponents to facilitate user motivation. Use a multidisciplinary team to design appropriate and effective patient education materials that emphasize motivation and encourage individuals to seek and obtain hearing health care. Professionals in the fields of education, gerontology, nursing, health psychology, and communication sciences and disorders could work collaboratively to design materials that address the complex health literacy needs of older adults because each profession has a unique perspective on the issues underlying the low use of hearing health care and strategies that can be used to motivate individuals to engage in healthy behaviors. Educational materials that are interactive, require users to make decisions and solve problems, model specific behaviors, and divide complex topics into smaller sub-topics enhance learning and motivation. Finally, there was a notable absence of graphics among PEMs. This is also related to user motivation because relevant graphics can attract attention, help model specific behaviors that are difficult to describe in writing, and support memory and comprehension of materials. Including relevant graphics within PEMs on ARHL may help enhance the usability and comprehensibility of these materials.
Having effective educational materials on hearing loss is one of the key approaches to improving access to affordable hearing health care. However, our study found that publicly available and widely used PEMs on ARHL are not suitable for the intended audience. This is problematic considering the serious negative consequences associated with undiagnosed and unmanaged hearing loss, which include reduced physical, psychosocial, and cognitive outcomes. The lack of suitable educational resources on ARHL serves as a barrier to accessing hearing health care. Efforts should be made to modify existing PEMs on ARHL, with careful consideration of the characteristics of the target audience, because factors, such as age, can impact a person’s ability to obtain, appraise, understand, and use health information. The findings of this study suggest that modifications should focus on reducing literacy demands, summarizing and highlighting key information, and subdividing topics into small, comprehensive units of information. Older adults, in particular, would benefit from typographic features such as increased font size and high contrast between font and paper as well as a writing style that uses the active voice and simple syntax. Existing PEMs on ARHL must be redesigned to account for the health literacy needs of older adults, who may have reduced visual and auditory acuity, as well as reduced working memory and processing speed.
1. U.S. Department of Health and Human Services (HHS), Office of Disease Prevention and Health Promotion (ODPHP). (2010). National Action Plan to Improve Health Literacy. Washington, DC: Author.
2. Brega, A. G., Barnard, J., Mabachi, N. M., Weiss, B. D., DeWalt, D. A., Brach, C., West, D. R. (2015). AHRQ health literacy universal precautions toolkit (2nd ed.). Prepared by Colorado Health Outcomes Program, University of Colorado Anschutz Medical Campus under Contract No. HHSA290200710008, TO#10. AHRQ Publication No. 15-0023-EF. Rockville, MD: Agency for Healthcare Research and Quality.
3. National Assessment of Adult Literacy (NAAL). (2016). Health literacy: Highlights of findings. Retrieved from https://nces.ed.gov/naal/health_results.asp.
4. Doak, C., Doak, L. G., & Root, J. H. (1996). Assessing suitability of materials. Teaching patients with low literacy skills, 41-60.
5. Caposecco, A., Hickson, L., & Meyer, C. (2014). Hearing aid user guides: Suitability for older adults. International Journal of Audiology, 53(1), S43-S51.
6. Laplante-Lévesque, A., Brännström, K. J., Andersson, G., & Lunner, T. (2012). Quality and readability of English-language internet information for adults with hearing impairment and their significant others. International Journal of Audiology, 51(8), 618-626.
7. Laplante-Lévesque, A., & Thorén, E. S. (2015). Readability of Internet information on hearing: Systematic literature review. American Journal of Audiology, 24(3), 284-288.
8. Simpson, A., Le, M., & Malicka, A. N. (2018). The accuracy and readability of Wikipedia on hearing loss. Journal of Consumer Health on the Internet, 22(4), 323-336.
9. Squires, E. S. & Ou, H. (in press). Do we have effective patient education materials for age-related hearing loss? American Journal of Audiology.
10. Kincaid, J. P., Fishburne Jr., R. P., Rogers, R. L., & Chissom, B. S. (1975). Derivation of new readability formulas (automated readability index, fog count and flesch reading ease formula) for navy enlisted personnel. Institute for Simulation and Training, 56.
11. Gunning, R. (1969). The fog index after twenty years. Journal of Business Communication, 6(2),3-13.