Printed education materials are often used to augment healthcare professionals’ verbal information to patients. Asthma is one of the commonest chronic diseases managed in general practice, and many leaflets have been produced on its diagnosis, prognosis, management, and treatment, but these have been subjected to little critical review.
Subjects, methods, and results
We evaluated the readability and accuracy of patient information leaflets available in general practice for asthmatic patients. We invited 70 general practices from the Wessex Research Network to send one copy of each of the leaflets they had on asthma: 168 different leaflets were received from 49 practices. We reviewed the leaflets for readability using the simple measure of gobbledegook (SMOG) formula, which estimates the level of education required to understand the text.1 AF reviewed the leaflets for congruency with current British Thoracic Society guidelines2 and accuracy in other areas.
The reading grade for these publications ranged from 5 to 12 (mode 8, mean 8.66 (SD 1.79)) (table), and 39 (23%) contained inaccuracies.
The British Thoracic Society guidelines were not applicable to 78 of the leaflets. Of the rest, 58 were fully congruent, 21 were >90% accurate, and 11 were inaccurate. Six inaccurate leaflets were produced by charities, the other five by drug companies. Seven of these leaflets contained therapeutic advice that was out of date. One recent publication ignored the effects of chronic exposure to cats. Another denied the presence of inflammation in mild disease. Three of the inaccurate leaflets had no publication date, and all but one of the rest were at least six years old; several practices sent a leaflet 13 years old.
Thirty four leaflets (20%) contained inaccurate or misleading statements about areas outside the society guidelines. These included unreasonable advice on the need to see a doctor, exaggerating the role of cola drinks as a trigger, inexact advice on avoiding house dust mite allergens, incorrect information on the efficacy of desensitising injections, wrong contact addresses and telephone numbers, and misinformation about obtaining a peak flow meter and not acknowledging the wide range of devices available.
Comment
Five and a half million people in Britain have reading difficulties,3 and considerably more (22% of the working population) have a low level of literacy.4 Text with SMOG scores under 5 will be understood by most people (information from Basic Skills Agency, 1992), and it is recommended that health literature should be written at a SMOG score ⩽5.5 To attain high levels of reader comprehension would require revision of 97% of the leaflets we reviewed. Rather than attempting wholesale revision, it is more realistic to match readers with existing materials and to strive for low readability scores in replacement leaflets.
Readability formulae have limitations; ideally, testing with patients should also be done as reading is a complex process and ability to comprehend a text is influenced by presentation (organisation, print, illustrations), situation (stress), and reader characteristics (motivation, maturity). Formulae based on word length disregard patients’ familiarity with the vocabulary associated with their illness, thereby overestimating the difficulty of the text.
None of the inaccuracies highlighted posed a serious threat to patient wellbeing, but patients deserve to receive complete, current information about treatment and health education. Practices sent copies of every leaflet that they had, so this may have included leaflets not normally used. Less desirable leaflets may not be given to patients, but while these remain in the practice there is the potential that they may be used.
To ensure that patients receive good advice we recommend that healthcare professionals read leaflets before giving them to patients to ensure that the content is accurate and up to date; assess patients’ reading abilities and select material to suit; and, perhaps most importantly, review stocks of leaflets regularly and discard those that are out of date or inaccurate to reduce the risk of misinforming patients.
Table.
Readability of patient information leaflets about asthma
| SMOG grade* | No (%) of leaflets (n=104)† | Cumulative % |
|---|---|---|
| 5 | 3 (2.9) | 2.9 |
| 6 | 10 (9.6) | 12.5 |
| 7 | 12 (11.5) | 24.0 |
| 8 | 27 (26.0) | 50.0 |
| 9 | 19 (18.3) | 68.3 |
| 10 | 18 (17.3) | 85.6 |
| 11 | 5 (4.8) | 90.4 |
| 12 | 10 (9.6) | 100.0 |
Simple measure of gobbledegook (SMOG) readability grades 3-8 are equivalent to reading ability of people with a primary level of education, grades 9-12 are equivalent to those with secondary level education.
Sixty leaflets were too short to analyse (<30 sentences), four leaflets were excluded because they were not written in English.
Acknowledgments
We thank all the practices that took part in the study and the administrative and support staff of the Wessex Research Network—Joan Dunleavey, Christine Tresise, and Sylvia Craigie-Halkett.
Editorial by Coulter
Footnotes
Funding: Grant from Allen and Hanburys.
Conflict of interest: None.
References
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