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Appendix E: Strategies for Providing Information to Clients

The client should receive and understand the information she or he needs to make informed decisions and follow treatment plans. This requires careful attention to how information is communicated. The following strategies can make information more readily comprehensible to clients:

Strategies for Providing Information to Clients

Educational materials should be provided that are clear and easy to understand. Educational materials delivered through any one of a variety of media (for example, written, audio/visual, computer/web-based) need to be presented in a format that is clear and easy to interpret by clients with a 4th to 6th grade reading level (13). Many adults have only a basic ability to obtain, process, and understand health information necessary to make decisions about their health (4). Making easy-to-access materials enhances informed decision-making (13). Test all educational materials with the intended audiences for clarity and comprehension before wide-scale use.

The following evidence-based tools provide recommendations for increasing the accessibility of materials through careful consideration of content, organization, formatting, and writing style:

Information should be delivered in a manner that is culturally and linguistically appropriate. In presenting information it is important to be sensitive to the client's cultural and linguistic preferences (5,6). Ideally information should be presented in the client's primary language, but translations and interpretation services should be available when necessary. Information presented must also be culturally appropriate, reflecting the client's beliefs, ethnic background, and cultural practices. Tools for addressing cultural and linguistic differences and preferences include

The amount of information presented should be limited and emphasize essential points. Providers should focus on needs and knowledge gaps identified during the assessment. Many clients immediately forget or remember incorrectly much of the information provided. This problem is exacerbated as more information is presented (79). Limiting the amount of information presented and highlighting important facts by presenting them first improves comprehension (1014).

Numeric quantities should be communicated in a way that is easily understood. Whenever possible, providers should use natural frequencies and common denominators (for example, 85 of 100 sexually active women are likely to get pregnant within 1 year using no contraceptive, as compared with 1 in 100 using an IUD or implant), and display quantities in graphs and visuals. Providers also should avoid using verbal descriptors without numeric quantities (for example, sexually active women using an IUD or implant almost never become pregnant). Finally, they should quantify risk in absolute rather than relative terms (for example, "the chance of unintended pregnancy is reduced from 8 in 100 to 1 in 100 by switching from oral contraceptives to an IUD" versus the chance of unintended pregnancy is reduced by 87%). Numeracy is more highly correlated with health outcomes than the ability to read or listen effectively (15). The strategies listed above can help clients interpret numeric quantities correctly (1628).

Balanced information on risks and benefits should be presented and messages framed positively. In addition to discussing risks, contraindications, and warnings, providers should discuss the advantages and benefits of contraception. In presenting this information, providers should express risks and benefits in a common format (for example, do not present risks in relative terms and benefits in absolute terms), and frame messages in positive terms (for example "99 out of 100 women find this a safe method with no side effects," versus "1 out of 100 women experience noticeable side effects"). Many clients prefer to receive a balance of information on risks and benefits (29), and using a common format avoids bias in presentation of information (18,22,26,30). Framing messages positively increases acceptance and comprehension (18,22,31,32).

Active client engagement should be encouraged. Providers should use educational materials that encourage active information processing (e.g., questions, quizzes, fill-in-the-blank, web-based games, and activities). In addition, they should be sure the client has an opportunity to discuss the information provided, and when speaking with a client, providers should engage her or him actively. Research has indicated that interactive materials improve knowledge of contraceptive risks, benefits, and correct method use (33–35). Clients also value spoken information (29,36); and educational materials, when delivered by a provider, more effectively increase knowledge (10,37). In particular, presenting information in a question and answer format is more effective than simply presenting the information (10,15,3741).

References

  1. Centers for Medicare and Medicaid Services. Toolkit for making written material clear and effective. Baltimore, MD: Centers for Medicare and Medicaid Services; 2011.
  2. US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Health literacy online: A guide to writing and designing easy-to-use health Web sites. Washington, DC: US Department of Health and Human Services; 2010.
  3. DeWalt D, Callahan L, Hawk V, et al. Health literacy universal precautions toolkit. AHRQ Publication No. 10–0046-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2010.
  4. Kutner M, Greenberg E, Jin Y, Paulsen C. The health literacy of America's adults: results from the 2003 National Assessment of Adult Literacy (NCES 2006–483). Washington, DC: U.S. Department of Education: National Center for Education Statistics; 2006.
  5. Olavarria M, Beaulac J, Belanger A, Young M, Aubry T. Organizational cultural competence in community health and social service organizations: how to conduct a self-assessment. J Cult Divers 2009;16:140–50.
  6. Tucker C. Reducing health disparities by promoting patient-centered culturally and linguistically sensitive/competent health care. U.S. Department of Health and Human Services Advisory Committee on Minority Health, US Public Health Service; 2009.
  7. Anderson JL, Dodman S, Kopelman M, Fleming A. Patient information recall in a rheumatology clinic. Rheumatol Rehabil 1979;18:18–22.
  8. Crane JA. Patient comprehension of doctor-patient communication on discharge from the emergency department. J Emerg Med 1997;15:1–7.
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  10. Little P, Griffin S, Kelly J, Dickson N, Sadler C. Effect of educational leaflets and questions on knowledge of contraception in women taking the combined contraceptive pill: randomised controlled trial. BMJ 1998;316:1948–52.
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  12. Peters E, Dieckmann N, Dixon A, Hibbard JH, Mertz CK. Less is more in presenting quality information to consumers. Med Care Res Rev 2007;64:169–90.
  13. Steiner MJ, Dalebout S, Condon S, Dominik R, Trussell J. Understanding risk: a randomized controlled trial of communicating contraceptive effectiveness. Obstet Gynecol 2003;102:709–17.
  14. Berry DC, Michas IC. Rosis F. Evaluating explanations about drug prescriptions: Effects of varying the nature of information about side effects and its relative position in explanations. Psychol Health 1998;13:767–84.
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  16. Berry DC. Informing people about the risks and benefits of medicines: implications for the safe and effective use of medicinal products. Curr Drug Saf 2006;1:121–6.
  17. Berry DC, Raynor DK, Knapp P, Bersellini E. Patients' understanding of risk associated with medication use: impact of European Commission guidelines and other risk scales. Drug Saf 2003;26:1–11.
  18. Edwards A, Elwyn G, Mulley A. Explaining risks: turning numerical data into meaningful pictures. BMJ 2002;324:827–30.
  19. Galesic M, Gigerenzer G, Straubinger N. Natural frequencies help older adults and people with low numeracy to evaluate medical screening tests. Med Decis Making 2009;29:368–71.
  20. Garcia-Retamero R, Galesic M. Communicating treatment risk reduction to people with low numeracy skills: a cross-cultural comparison. Am J Public Health 2009;99:2196–202.
  21. Garcia-Retamero R, Galesic M, Gigerenzer G. Do icon arrays help reduce denominator neglect? Med Decis Making 2010;30:672–84.
  22. Gigerenzer G, Edwards A. Simple tools for understanding risks: from innumeracy to insight. BMJ 2003;327:741–4.
  23. Knapp P, Gardner PH, Raynor DK, Woolf E, McMillan B. Perceived risk of tamoxifen side effects: a study of the use of absolute frequencies or frequency bands, with or without verbal descriptors. Patient Educ Couns 2010;79:267–71.
  24. Kurz-Milcke E, Gigerenzer G, Martignon L. Transparency in risk communication: graphical and analog tools. Ann N Y Acad Sci 2008;1128:18–28.
  25. Lipkus IM. Numeric, verbal, and visual formats of conveying health risks: suggested best practices and future recommendations. Med Decis Making 2007;27:696–713.
  26. Paling J. Strategies to help patients understand risks. BMJ 2003;327:745–8.
  27. Skolbekken JA. Communicating the risk reduction achieved by cholesterol reducing drugs. BMJ 1998;316:1956–8.
  28. Visschers VH, Meertens RM, Passchier WW, de Vries NN. Probability information in risk communication: a review of the research literature. Risk Anal 2009;29:267–87.
  29. Raynor DK, Blenkinsopp A, Knapp P, et al. A systematic review of quantitative and qualitative research on the role and effectiveness of written information available to patients about individual medicines. Health Technol Assess 2007;11:iii, 1–160.
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  31. Armstrong K, Schwartz JS, Fitzgerald G, Putt M, Ubel PA. Effect of framing as gain versus loss on understanding and hypothetical treatment choices: survival and mortality curves. Med Decis Making 2002;22:76–83.
  32. Gurm HS, Litaker DG. Framing procedural risks to patients: is 99% safe the same as a risk of 1 in 100? Acad Med 2000;75:840–2.
  33. Paperny DM, Starn JR. Adolescent pregnancy prevention by health education computer games: computer-assisted instruction of knowledge and attitudes. Pediatrics 1989;83:742–52.
  34. Reis J, Tymchyshyn P. A longitudinal evaluation of computer-assisted instruction on contraception for college students. Adolescence 1992;27:803–11.
  35. Roberto AJ, Zimmerman RS, Carlyle KE, Abner EL, Cupp PK, Hansen GL. The effects of a computer-based pregnancy, STD, and HIV prevention intervention: a nine-school trial. Health Commun 2007;21:115–24.
  36. Grime J, Blenkinsopp A, Raynor DK, Pollock K, Knapp P. The role and value of written information for patients about individual medicines: a systematic review. Health Expect 2007;10:286–98.
  37. DeLamater J, Wagstaff DA, Havens KK. The impact of a culturally appropriate STD/AIDS education intervention on black male adolescents' sexual and condom use behavior. Health Educ Behav 2000;27:454–70.
  38. McMahon SR, Rimsza ME, Bay RC. Parents can dose liquid medication accurately. Pediatrics 1997;100:330–3.
  39. Belcher L, Kalichman S, Topping M, et al. A randomized trial of a brief HIV risk reduction counseling intervention for women. J Consult Clin Psychol 1998;66:856–61.
  40. Eldridge GD, St Lawrence JS, Little CE, et al. Evaluation of the HIV risk reduction intervention for women entering inpatient substance abuse treatment. AIDS Educ Prev 1997;9(Suppl):62–76.
  41. Jaccard J. Unlocking the contraceptive conundrum. Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy; 2009. Available at http://thenationalcampaign.org/resource/unlocking-contraception-conundrum.


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