Assessing health literacy and subsequent implementation of an animated video to enhance understanding for patients with nephrolithiasis

Abstract

Background

The use of visual aids to enhance patient learning is becoming increasingly common in medicine. Patients with a better understanding of surgical procedures tend to have better long-term outcomes due to the active seeking of help when complications occur postsurgery. We hypothesized that showing patients an animation of ureteroscopy with instructions on how to address potential complications would increase their understanding of the perioperative nature of ureteroscopy.

Methods and materials

Fifty patients were selected between May and August 2019. The group consisted of patients who had recently undergone ureteroscopy for nephrolithiasis or who would undergo ureteroscopy in the near future. Patients were given a prevideo assessment, followed by video and postvideo assessments. The prevideo and postvideo assessments were multiple choice and identical, except for 3 additional questions at the end of the postvideo assessment asking about patient opinions regarding the video. Patients were unaware that they would be completing a postvideo assessment until they had finished watching the video.

Results

When asked about the symptoms of a urinary tract infection postprocedure, 72% of patients answered incorrectly, with 58% choosing “go to the emergency department immediately,” in the prevideo assessment versus 6% in the postvideo assessment (p < 0.05). If bleeding was a possible side effect of the procedure, 20% versus 0% answered incorrectly (p < 0.05). When asked about stent placement after surgery, 6% versus 0% answered incorrectly. One hundred percent of patients in both assessments answered correctly that stones would be removed and a scope was inserted into the urethra. Ninety-four percent of patients noted the video was presented in a very clear way, 80% noted that the video increased their understanding of the procedure “a lot,” and 82% noted the video increased the quality of their visit “a lot.”

Conclusions

Using an animated video to explain ureteroscopy and laser lithotripsy is beneficial.

1. Introduction

Health literacy is defined as “a term employed to assess the ability of people to meet the increasing demands related to health in a rapidly evolving society.”^[1] Health literacy has several implications for access to health care services, social determinants of health, and overall surgical outcomes.^[1,2] The average adult reading level in the United States is currently at an 8th grade level. However, studies have shown that patient educational materials are often written above the 8th grade level.^[3] Patients with limited health literacy had worse health-related outcomes. This is especially true when multiple options for surgical intervention are present, such as in the treatment of kidney stones.

Nearly 1 of 11 Americans is affected by kidney stones, and the number continues to rise.^[4] This increase in prevalence may be attributed to the increasing rate of metabolic syndrome, obesity, poor dietary habits, and decreased fluid intake.^[5] Stones measuring <5 mm may pass on their own in up to 90% of cases, but larger stones often require intervention.^[6] Ureteroscopy is a favorable option for intervention, and in 2009, over 10,400 ureteroscopies were performed in the United States.^[7] The overall recurrence rate of stones is high at nearly 50% at 10 years.^[6] A large-scale study of 35,941 patients with nephrolithiasis who underwent ureteroscopy showed that 15% had an unplanned visit to the emergency department (ED) within 30 days after the procedure.^[8] The most common complaints for unplanned representation were pain or infection, and patients with multiple comorbidities were most likely to present.^[8]

Several studies have shown that using visual aids in combination with verbal communication improves patient understanding and treatment adherence.^[9] Other studies have shown that using a 3D physical model with counseling is effective in improving patient satisfaction, understanding, and outcomes.^[10] We hypothesized that low health literacy is common in patients with kidney stones and using an animated video to explain ureteroscopy will enhance patient understanding of ureteroscopy.

2. Materials and methods

Fifty patients were selected from the University of Kentucky Endourology Clinic between May and August 2019. The 50 patients were recruited from multiple providers, including physicians and physician assistants. The selection criteria for inclusion were current or recent history of kidney stone disease and ureteroscopy in the recent past (<6 months) or scheduled surgery within 6 weeks. Patients were recruited in real time during office visits by a medical student who was not affiliated with the patient care team. The medical student chart reviewed the patients and verified with the provider(s) that the patient met the selection criteria and was eligible for this study. Then, only the remainder of the study proceeds. The medical student then interviewed the patients individually, shortly after discussion with the provider had taken place. Translation services are available to non-English speakers. This study was approved by the institutional review board.

A brief validated health literacy screen (BHLS) was employed to provide an objective measure of health literacy levels in these patients (Fig. 1). The BHLS was developed and piloted by Jecklin et al.^[11] and attaches numeric values to patient responses. A total score of less than 19 indicated low health literacy. This cutoff provides the best combination of sensitivity and specificity (0.60 and 0.83, respectively). The BHLS was specifically designed to be read to patients to allow patients with low reading ability to complete the assessment.^[11] The medical student verbally administered the BHLS to each patient in the clinic selected for this study.

Figure 1.

Brief health literacy screen.

After the patients had completed the BHLS, they read a 6-question prevideo assessment encompassing the purpose, procedure, side effects, and complications of ureteroscopy. The prevideo assessment was made to be at the 8th grade level based on the Flesch–Kincaid readability level to reflect the average reading level of the general population. The patients were then shown a 2.5-minute animated video explaining the purpose, procedure, side effects, and complications of ureteroscopy. The animated video was developed by the urology department's endourology division in conjunction with a medical illustrator (https://www.youtube.com/watch?v=NbbYb5ZzjlQ). In addition to viewing the video, patients received preoperative counseling from their respective providers. This counseling was not standardized across different providers.

After this, patients were administered a postvideo assessment consisting of the same 6 questions as in the prevideo assessment, as well as 3 additional questions (questions numbered 7–9), assessing the benefits of the video (Fig. 2). In addition, a free-text area was included to record additional responses to the video. The patients were not told that they would be given this postvideo assessment before viewing the video. The prevideo and postvideo assessment questions were formulated by 4 faculty endourologists.

Figure 2.

Ureteroscopy postvideo assessment.

3. Results

3.1. Health literacy results

Thirty percent of the patients interviewed were determined to have low health literacy, based on a score of less than 19. Further analysis of individual responses showed 22% of the patients always needed someone to help them read medical forms. Thirty percent of the interviewed patients noted that they were less than “quite confident” in filling out medical forms by themselves. Twenty-six percent of interviewed patients noted that they were more than “occasionally” having problems learning about their health information because of trouble understanding written health information. Sixteen percent of interviewed patients noted that they were more than “occasionally” having trouble understanding what their doctor, nurse, or pharmacist tells them about their health or treatments. Thirty-six percent of interviewed patients noted that they more than “occasionally” had trouble remembering instructions from the doctor, nurse, or pharmacist after they got home.

3.2. Video assessment results

The results of the prevideo and postvideo assessments are displayed in Figure 3. When asked about addressing symptoms of a urinary tract infection (UTI) postprocedure, 72% of patients answered incorrectly, with 58% choosing “go to the ED immediately,” in the prevideo assessment versus 6% in the postvideo assessment (p < 0.05). Regarding bleeding as a possible side effect of the procedure, 20% versus 0% answered incorrectly (p < 0.05). When asked about stent placement after surgery, 6% versus 0% answered incorrectly. One hundred percent of patients in both assessments answered correctly that stones would be removed and a scope was inserted into the urethra. Ninety-four percent of patients noted the video was presented in a very clear way, 80% noted that the video increased their understanding of the procedure “a lot,” and 82% noted the video increased the quality of their visit “a lot.”

Figure 3.

Comparison of correct answers in prevideo versus postvideo assessment.

From the feedback obtained from patients, a recurring theme was that they wished they had seen the video beforehand. One patient directly quoted, “this video was very helpful, I feel like I had a better understanding of what was going on and what to expect after seeing this video.” Another patient mentioned, “the best part about the video was the ability to understand what the healing process was like and what signs to look out in case anything wrong happened.” Other patients mentioned that because the video was available on YouTube, it was beneficial because if they had questions about the procedure, they could rewatch the video. Patients also noted that combining the narration from the video with animation further helped bridge the gaps in counseling. A few patients even noted “these kinds of videos should be shown for every procedure.”

Twenty-two percent of the patients mentioned having lower levels of anxiety after watching the video. Of note, all the patients who experienced lower levels of anxiety had not yet undergone ureteroscopy, thus demonstrating the potential benefit of showing procedural videos to preoperative patients.

4. Discussion

Thirty percent of the patients in this study had limited health literacy, with another 14% scoring very close to limited health literacy. Twenty-two percent of patients needed assistance reading forms, and 36% of the patients had trouble remembering instructions from their health care provider when they got home.

Low health literacy is common across several disciplines in medicine and leads to several negative outcomes secondary to the misinterpretation of information.^[12] This is in line with the current literature, which shows that patients with low health literacy are more likely to have difficulty finding care and, therefore, delay care. This holds true across employment status, race, ethnicity, poverty level, and cognitive function level.^[13] Complications secondary to poor health literacy can affect several aspects of surgical care. A lack of compliance with preoperative care instructions can result in delayed or canceled procedures. Patients with low health literacy may have difficulty actively participating in preprocedural counseling, resulting in a lack of understanding of when to seek help if complications arise. These factors contribute to prolonged hospital stay and worse outcomes.^[14] Ultimately, patients with low health literacy levels have a nearly 2-fold increase in mortality rate.^[9] From a financial standpoint, low health literacy results in an additional $50 to $73 billion in annual health care costs.^[9]

Studies show that spending more time explaining a diagnosis instead of just focusing on treatment is beneficial to patient understanding and subsequently reduces misconceptions about disease processes.^[15] In addition, creating educational material focused on a proper reading level for the general patient population could enhance understanding and have a positive impact on patient care.^[16] Visual aids, such as physical models, have been shown to increase patient satisfaction, strengthen compliance, and improve the physician-patient relationship.^[10] Confirming understanding using reinforcement and the teach-back approach have been shown to be an effective strategy after counseling.^[15] Finally, training medical professionals to create empowering environments in the clinical setting is recommended to reduce stigmatization and encourage patients to ask for clarification when needed.^[15]

In an effort to enhance medical understanding among patients treated for kidney stones with ureteroscopy, the endourology division decided to create a video in conjunction with a medical illustrator. The video included a description of the reason for the procedure, real-time animation depicting how the procedure actually took place, and an explanation of side effects and possible complications. The results from the prevideo survey showed that the patients interviewed knew why they were undergoing ureteroscopy. However, 20% of the patients did not know that hematuria was a normal side effect. Furthermore, 72% of patients did not know what to do if they began experiencing symptoms of UTI, a known complication of ureteroscopy.^[17] In fact, of the 72% of patients who incorrectly answered the UTI question, 58 chose “to go to the ED” as their answer choice. This common misconception that UTI symptoms are a reason for presenting to the ED may contribute to the 15% unplanned emergency room return rate after ureteroscopy.^[8] However, after watching the video, 100% of patients knew that hematuria is a normal side effect, and >90% knew what to do if they developed UTI symptoms. In addition, patients' responses to the video were positive. Many patients had an idea of what the procedure was, but seeing the animation showed them more intricacies that were not otherwise known. For instance, 36% of the patients knew that a laser would bust the kidney stone into smaller fragments, but they did not know that a basket might be used to retrieve the fragments.

The current literature in urology and other surgical specialties shows that gaps in health literacy led to poorer outcomes, and strategies have been demonstrated to try and improve these gaps. Hu et al.^[10] showed that the use of a 3D visual model of the urinary system to explain ureteroscopy and other urological procedures improved patient understanding and compliance. Merandy et al.^[18] used a video along with written educational materials to counsel patients with bladder cancer and demonstrated that these patients had increased postprocedural self-care skills, such as changing urostomy appliances. Our work is the first to study video combining visual models with narration to improve health literacy among patients with nephrolithiasis undergoing ureteroscopy. The video assists patients in understanding why and how the procedure is performed and what the next steps should be taken if complications arise. Because it is on YouTube, the video is widely available to be watched at any time, giving reassurance to patients who have trouble remembering counseling advice. Finally, this standardized approach to counseling can ensure that patients receive the same information that might differ if they are given verbally by different medical providers. This is one of the reasons why the study decided not to compare the results of the assessment questions between patients who did and did not view the videos. Patients who had not viewed the video would only have received preoperative counseling from their provider, and because the process is not standardized, it would be inaccurate to assess their knowledge of the procedure/complications because the information given is at each provider's discretion.

Recent studies have suggested higher levels of stress in patients with lower health literacy.^[19] The reasons behind this link are still being investigated; however, interventions to promote health literacy in patients have been shown to significantly reduce anxiety.^[20] Showing the video resulted in 22% of patients reporting lower levels of anxiety. Of note, all patients who mentioned having lower levels of anxiety had not yet undergone ureteroscopy. This supports the importance of presurgical, postsurgical, and predischarge counseling. Poor counseling can lead to unpreparedness for complications, worse outcomes, and increased stress and anxiety in patients and caregivers.^[21] Coping is defined as thoughts and behaviors used to deal with stressful situations and is categorized into 4 major categories. One of the categories termed “problem-focused” address the problem causing distress (surgery in this case) through different mechanisms like “planning.”^[21] By using counseling strategies, such as incorporating the video, patients could “plan” for their operative course and know the next steps to if any complications arose. Understanding the procedures and complications that can arise is an essential part of lowering anxiety levels, especially in preoperative patients.

Limitations

Despite the benefits of videos, our study has some limitations. It was unclear whether the number of subjects used in the study was sufficient to reflect the health literacy of the entire patient population. In addition, the ethnic breakdown of patients seen in the urology clinic was 44 native English speakers and 6 native Spanish speakers. Because the population of non-English speakers in this study was low, the health literacy rate found in this study is likely to overestimate the true health literacy rate in the entire population. Lastly, patients who had already undergone the procedure were more likely to know the side effects after the surgery than those who had not yet undergone surgery.

5. Conclusions

Using an animated video to explain ureteroscopy and laser lithotripsy procedures and risks was beneficial for patient understanding and appreciation. Further studies to find ways to increase patient understanding of disease and management are warranted, especially in populations with large numbers of non–English-speaking patients. It would also be valuable in future studies to report on patient outcomes, such as unplanned ED visits, which were impacted by watching the video or administering the postvideo assessment at different time points after the video.

Conflict of interest statement

The authors declare no direct or indirect conflict of interest related to this study.