A printed information leaflet about MRI and radiologists improves neuroradiology patient health literacy

Abstract

Purpose

To determine the health literacy benefit of a printed informational leaflet for patients scheduled to undergo brain magnetic resonance imaging (MRI) scans.

Methods and materials

A two-page leaflet that provided an overview of MRI and the role of radiologists was prepared and given to outpatients scheduled to undergo brain MRI examinations while in the waiting room. A survey composed mainly of yes/no and Likert scale questions pertaining to the leaflet, as well as patient demographics, was administered to the patients.

Results

A total of 147 patients completed the survey, of which 110 (75%) had undergone a prior MRI scan, 120 (82%) stated that their ordering provider explained the reason for the MRI scan, and less than 1% reported having referenced online resources related to MRI. The average score for how well patients understood the MRI scan procedure and how it is reviewed was 4.16/5 (standard deviation 1.18) before versus 4.39/5 (standard deviation 1.08) after reading the leaflet, which was a statistically significant improvement based on the Wilcoxon signed-rank test (P < 0.01). The score for how helpful the reading material was for explaining what is MRI was 4.06/5 (standard deviation 1.02) and the score for how helpful the reading material was for explaining what is a radiologist was 4.18/5 (standard deviation 0.98).

Conclusion

A printed leaflet about MRI and radiologists can serve as an opportunity to educate patients about certain aspects of their scans during their stay in the waiting room.

Introduction

Patient health literacy is perhaps the single best predictor of health status and is defined as the capacity to obtain, interpret and understand basic health information and services, and the ability to use such information and services to enhance health.¹ Studies suggest that those with limited health literacy skills are significantly more likely than individuals with adequate health literacy skills to characterize their health as poor.² Furthermore, the rates of hospitalization and use of emergency services are higher among patients with limited health literacy skills, which in turn is associated with higher healthcare costs.³

The issue of patient health literacy is particularly relevant to radiology. Public recognition of the role of radiology is important and dependent on communication with patients. However, apparently over the past years radiologists have become less visible to the public in general.⁴ Indeed, it has been reported that patients are not well informed about ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI).⁵ Furthermore, it has been reported that educational materials across various medical specialties were too complex for the average patient.⁶ Consequently, the American College of Radiology has endorsed that radiologists should implement new policies and procedures to deliver patient-centered communication. Thus there is an opportunity to enhance patient health literacy with respect to radiology. Although it is impractical for most radiologists to communicate directly with patients, printed materials prepared by radiologists can potentially serve as a suitable surrogate.

The US National Institutes of Health has provided guidelines for developing effective print materials for a low-literacy audience, which can be tailored for particular patient populations by implementing pretests and revisions.⁷ Ultimately, the utilization of some terminology that is deemed to be college level, such as ‘magnetic resonance imaging’ is inevitable, but is familiar to virtually all patients who undergo such scans. Indeed, the algorithms used by readability assessment systems include quantitative parameters, such as the number of letters, syllables, words and sentences used in the text, and may lead to inaccurate scores for medical terminology.⁸ Nevertheless, the use of illustrations in the leaflets can potentially increase patient understanding.

The purpose of this study was to determine how informative a printed leaflet consisting of text and images about MRI and radiologists is for patients scheduled to undergo a brain MRI scan. In particular, we hypothesized that patients scheduled to undergo brain MRI scans would find the leaflet at least somewhat helpful and have a significantly greater understanding of MRI and the role of radiologists after reading the leaflet.

Materials and methods

A double-sided laminated leaflet pertaining to brain MRI with text and images was prepared, including the following sections: ‘What is MRI?’ and ‘What is a radiologist?’ (Appendix 1). Between January 2017 and June 2017 the leaflets were distributed to adult outpatients scheduled for brain MRI examinations by the receptionists on arrival in the MRI suite waiting room, and were completed prior to meeting a technologist and undergoing the scan. A survey consisting of yes/no questions and bipolar five-point Likert scale questions, as well as demographic questions (Appendix 2) was administered to the patients after reading the leaflet. The readability of the leaflet text was assessed using several indices, including the Flesch–Kincaid grade level, the Coleman–Liau index, the SMOG index, the automated readability index and the Linsear write formula.⁹

The Wilcoxon signed-rank test was used to compare the differences in how well patients perceived their understanding of the MRI scan procedure and how it is reviewed before compared with after reading the leaflet. The two-tailed t-test was used to compare the differences in how well patients perceived their understanding of the material in the leaflet among those with college education or greater versus those with high school education or less. A P value of less than 0.05 was considered significant.

The study was approved by the Office of Clinical Effectiveness, because it was determined to be quality improvement and therefore was not considered human subject research. No patient identifiers were recorded and consent as waived.

Results

All of the 147 patients who were offered the survey accepted to review the leaflet and completed the questionnaire, with the results listed in Table 1. Overall, the majority (68%) of patients found the length of the leaflet to be just right. The majority (75%) of patients surveyed had had a prior MRI examination and most (82%) reported that their referring physician explained the reason for the MRI they were scheduled to undergo, but very few (<1%) previously consulted online resources pertaining to their MRI.

Table 1.

Survey results.

Question	Result
1. Have you had a prior MRI examination?	Yes: 110 (75%) No: 37 (25%)
2. Did your doctor explain to you why you are getting an MRI today?	Yes: 120 (82%) No: 26 (18%)
3. Have you referenced any online resources related to your MRI?	Yes: 1 (<1%) No: 139 (>99%)
4. How well did you understand the MRI scan procedure and how it is reviewed before reading the leaflet?	4.16 (SD 1.18) out of maximum of 5 points
5. How well do you understand the MRI scan procedure and how it is reviewed after reading the leaflet?	4.39 (SD 1.08) out of maximum of 5 points
6. Did you understand the material in the leaflet?	4.24 (SD 0.98) out of maximum of 5 points
7. What do you think about the length of the reading material?	3.43 SD 0.85) out of maximum of 5 points
8. How helpful was the reading material for explaining what is MRI?	4.06 (SD 1.02) out of maximum of 5 points
9. How helpful was the reading material for explaining what a radiologist is?	4.18 (SD 0.98) out of maximum of 5 points
10. What is your age?	18–24 years: 9 (6%); 25–34 years: 10 (7%); 35–44 years: 14 (10%); 45–54 years: 27 (19%); 55–64 years: 35 (25%); 65–74 years: 31 (22%); 75 years or older: 15 (11%)
11. What is the highest level of education you have received?	High school or less: 32 (23%) Some college or greater: 104 (77%)
12. Would you have liked to receive information about the MRI by email before the scan, if possible?	Yes: 33 (25%) No: 105 (75%)

MRI: magnetic resonance imaging; SD: standard deviation.

Overall, the vast majority (94%) of patients perceived that the leaflet was at least somewhat helpful in explaining what MRI is, and the vast majority (96%) of patients also perceived that the leaflet was at least somewhat helpful in explaining what a radiologist is.

There was a statistically significant difference for how well patients understood the MRI scan procedure and how it is reviewed before versus after reading the leaflet (P < 0.01). The average degree of understanding of the material in the leaflet was 3.7/5 (standard deviation (SD) 1.0) for patients with high school education or less versus 4.4/5 (SD 0.9) for those with at least some college education (P = 0.001). Nevertheless, patients with a high school education or less reported a greater increase in understanding about the MRI examination than those with at least some college education after reading the leaflet (Table 2).

Table 2.

Improvement of understanding about MRI before and after leaflet versus educational level.

	College education or greater			High school education or less
	Before leaflet	After leaflet	Improvement	Before leaflet	After leaflet	Improvement
Degree of understanding about MRI	4.25 (SD 1.13) out of maximum of 5 points	4.49 (SD 0.83) out of maximum of 5 points	0.24*	3.87 (SD 1.31) out of maximum of 5 points	4.20 (SD 0.89) out of maximum of 5 points	0.33*

^*P < 0.01.

MRI: magnetic resonance imaging; SD: standard deviation.

The various age groups were fairly well represented among the patients surveyed, with 44% of patients aged between 18 and 54 years and 56% of patients aged 55 years and older. Regardless of age, the majority (75%) of patients preferred not to receive information about the MRI scan by email before the scan.

Discussion

Although the majority of patients surveyed in this study previously underwent at least one MRI scan and stated that their physicians had explained to them why they were getting the MRI scan, the leaflet significantly increased their perceived understanding about the MRI scan procedure and how it is reviewed. This suggests that referring clinicians may not provide a comprehensive overview of the subject matter. Yet, it has been found that increased information about the MRI scanning procedure can lead to decreased motion artifacts and thus better quality images.¹⁰ Although MRI technologists have an opportunity to discuss such issues with patients prior to the scans, the effectiveness of such communication might vary from one technologist to another. Furthermore, providing leaflets that describe the role of radiologists can provide a different perspective and help promote the visibility of the specialty to patients and thereby combat risks of the perceived ‘invisible’ radiologist,¹¹ particularly in circumstances in which direct interaction between radiologists and patients is not feasible.

As expected, patients with high school education or less expressed a lower baseline understanding of the MRI scan procedure and how it is reviewed, and had a lower level of understanding than patients with college education or greater. However, although the readability of the leaflet text was estimated to be college level, patients with a high school level of education or lower perceived a greater incremental benefit than those with at least some college education. This implies that reading material that contains some unavoidable technical terms can confer the greatest health literacy benefit to the patients who need it the most. However, further optimization and testing of the readability of the leaflet for patients with lower educational levels may be useful.

Despite the widespread availability of online patient portals related to radiology,¹² our finding that less than 1% of patients sought online information related to their scheduled MRI examination is concordant with earlier literature related to ultrasound, CT and MRI, whereby fewer than 2% of patients searched the internet.⁵ Furthermore, few internet sites provide the range of information patients may need before an imaging examination.^13–16 Thus it appears that conferring information about the MRI procedure by means of a printed leaflet just before the scan serves as a unique opportunity for radiologists to educate patients in this regard.

Emailing the identical information to the printed leaflet made available in the waiting room may not have as much impact, because most patients indicated that they would not be receptive to this mode of delivery despite generally finding the leaflet to be informative. Indeed, it has been reported that family medicine patients value health information materials in the waiting rooms of family physicians, and that they perceive such materials as being helpful in improving patient–physician interaction, health-related knowledge and self-management.¹⁷ On the other hand, it has been found that there is no compelling evidence to support the use of email for the provision of information on disease prevention and health promotion.¹⁸

Conclusion

Our survey of patients scheduled to undergo MRI of the brain suggests that a printed leaflet about MRI and radiologists can serve as an opportunity to educate patients about their scan and the role of radiologists during their stay in the waiting room.

Appendix 1

What is MRI?

The MRI scanner is a large cylinder containing a magnet, with a central opening, as shown in Figure 1. A sliding table rests in the opening. You will lie on this narrow table and be comfortably positioned. A device called a ‘coil’ may be placed around the area being examined. This technology allows detailed images of the interior of the body to be produced.

Figure 1.

Photograph of an MRI scanner and head coil (arrow).

An MRI examination usually consists of several ‘sequences’, or sets of images, each lasting 2–5 minutes. Slight movement between sequences is allowed, but not during the sequences because this can degrade the quality of the images, as shown in Figure 2.

Figure 2.

Left: An example of a brain MRI performed at another institution shows blurring from motion, limiting the diagnostic utility. Right: A brain MRI obtained at our institution without motion shows exquisite anatomical detail.

What is a radiologist?

Radiologists are medical doctors who specialize in diagnosing and treating diseases using medical imaging techniques, such as X-rays, CT, MRI, nuclear medicine, positron emission tomography (PET) and ultrasound. The radiologist is not the technologist who works with you when making the images. Radiologists graduate from medical schools, pass licensing examinations, and then go on to complete a radiology residency of at least a total of 5 years devoted to studying imaging of the human body.

Radiologists also often complete a fellowship after residency. This is one or two additional years of specialized training in a particular subspecialty of radiology, such as neuroimaging, breast imaging, or nuclear medicine. Furthermore, radiologist physicians are typically board certified by the American Board of Radiology, an indication of a high level of training and demonstrated excellence in the field.

Appendix 2

Please answer a few questions about the reading material and MRI.

• 1. Have you had a prior MRI examination?

__ Yes

__ No

• 2. Did your doctor explain to you why you are getting an MRI today?

__ Yes

__ No

• 3. Have you referenced any online resources related to your MRI?

__ Yes: please list which one:

__ No

•  4. How well did you understand the MRI scan procedure and how it is reviewed before reading the leaflet?

1     2   3   4  5

Not at all   Somewhat   Completely

•  5. How well do you understand why you are getting an MRI today after reading the leaflet?

1     2   3   4  5

Not at all   Somewhat   Completely

•  6. Did you understand the material in the leaflet?

1     2   3   4  5

Not at all   Somewhat   Completely

•  7. What do you think about the length of the reading material?

1   2  3   4  5

Too brief Just right Too long (Next page please)

•  8. How helpful was the reading material in explaining what MRI is?

1    2   3    4  5

Not at all   Somewhat   Very much

•  9. How helpful was the reading material in explaining what a radiologist is?

1    2    3   4  5

Not at all   Somewhat   Very much

• 10. What is your age?

__18–24 years old __25–34 years old __35–44 years old __45–54 years old

__55–64 years old __65–74 years old __75 years or older

• 11. What is the highest degree or level of school you have completed? If currently enrolled, highest degree received?

__High school graduate or less

__At least some college

• 12. Would you have liked to receive information about the MRI by email before the scan, if possible?

__ Yes

__ No

Please provide any comments about the reading material:

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.