Expert answer:Evaluation of Printed Health Education Materials Q


Solved by verified expert:PLEASE USE the ATTACHED TEMPLATE to appraise the ATTACHED ARTICLE.Direct quoted material from the article may be used to help explain answers and identify components (must include article page number).Please address all questions – BRIEFLY with simple items, phrases, or (if required) a sentence or two.If a yes/no question – please answer as appropriate – if not applicable, please state – not applicable.List references ONLY IF other than the article being reviewed Helpful strategy – first view the critique template – to have an idea of what items to keep in mind when reading the article.


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Quantitative Study Critique- 75 points possible
The purpose of this assignment is to develop skills in reviewing and appraising research articles. Specific
details are considered to determine quality, utility, and evidence.
Review Chapter 4 in:
Polit, D. F., & Beck, C. T. (2018). Essentials of nursing research: Appraising evidence for nursing practice (9th ed.).
Philadelphia, PA: Lippincott Williams & Wilkins.
PLEASE USE THIS TEMPLATE for the assignment – save with your last name and submit in Canvas.
Direct quoted material from the article may be used to help explain answers and identify components (must
include article page number).
Please address all questions – briefly with simple items, phrases, or (if required) a sentence or two.
If a yes/no question – please answer as appropriate – if not applicable, please state – not applicable.
List references ONLY IF other than the article being reviewed or the course text.
Helpful strategy – first view the critique template – to have an idea of what items to keep in mind when reading
the article.
1. APA citation (2 points possible)
1.1. Provide the reference (authors, year, title, volume, issue, pages, doi) in correct APA format: (use italics
where appropriate, etc.) — (2 pt.)
2. Introduction: Problem and Purpose (3 points possible)
Is the problem clear, precise and well defined? Briefly identify. literature review/ (1 pt.)
Is a good argument made for the importance of the problem to clinical practice, research, theory, or
knowledge and policy development? Briefly explain. (2 pts)
3.Introduction: Background/ Literature Review (5 pts possible)
How many articles in the background /literature review are within and after five years of the
article’s publication date? (Often in published studies, the literature review is not a separate section
titled Literature Review, but a literature review is included in the Introduction or Background
section.)(1 pt)
What is the publication date range of the background/literature review articles? (1 pt.)
From what type of sources (studies, relevant organizations, media)? (1 pt.)
Are the current gaps in knowledge clearly presented? Briefly explain? (note: typically related to the
purpose for the study) (2 pt.)
4. Introduction: Conceptual/theoretical framework Research Questions or Hypotheses (5 points
Is a Research Question or PICO Question presented? If yes, please include here: (1 pt.)
Quantitative 19SU
Is a Hypothesis presented? If yes, please include here: (1 pt.)
Is a Theoretical or Conceptual Framework presented? If yes, please include here: (1 pt.)
What is the Main overall topic (in a broad sense) – i.e. childhood obesity, surgical site infections,
medical error? (2 pt.)
5. Method: Protection of Human Rights (8 pts possible l)
Was the study approved by an IRB? (1 pt.)
What appropriate procedures were used to safeguard the rights of all study participants?
Explain. (3 pts)
Were any vulnerable populations used in the study? If yes, who? (2 pt.)
What risks may subjects be exposed to while participating in the study? (2 pt.)
6. Method: Research Design (11 pts possible)
What was the type of quantitative research design used? (i.e. RCT, cross sectional, retrospective
analysis, cohort study?) (3 pts)
Is there an Independent Variable(s) (Intervention)? If yes, Identify here: (3 pt.)
Is there a Dependent Variable(s) (outcome)? If yes, Identify here: (3 pt.)
Is there a control group (experimental design)? If yes, Identify here: (1 pt.)
Is there a comparison group (non-experimental design)? If yes, Identify here: (1 pt.)
7. Method: Population and Sample (11 pts possible)
Who or what (if the sample includes material items) is identified as the target population/item? (2
How were the samples chosen (sampling method: i.e. randomly, convenience sampling, etc..)? (3
How large was the sample? (1 pt.)
What were the sample inclusion criteria and exclusion criteria? (2 pt.)
Did any of the participants drop out (attrition)? If yes, was it explained why (please share)? (1 pt.)
8. Method: Data collection and Measure (11 pts possible)
Quantitative 19SU
How were data collected? (3 pts)
What instruments or tools were used to collect data? (Did the researchers use already designed
tools/instruments/questionnaires/ lab or x-ray results OR design and build their own?) Identify
instruments by full title (not abbreviations). (3 pts)
Were the instruments reliable and valid? (Review your text for how instrument reliability and
validity are established.) Provide evidence for your response. (2 pts)
Were the data collected in a way that decreased bias? Explain. For example, was the staff collecting
data appropriately trained, or inter-rater reliability addressed? Explain. (3 pts)
9. Results: Data Analysis (4 pts possible)
Was a statistician or statistical software program (SPSS, SAS?) used for data analysis? (1 pt.)
Were these methods used appropriate for the study? Briefly explain how? (consider the aim of the
study: to describe, compare/difference, or explore relationship/correlation) (3 pts)
10. Discussion: Interpretation of the Findings (6 pts possible)
10.1 What were the major findings presented? Briefly Discuss. (3 pts)
Were tables and figures used? (1 pts)
Were all research questions/hypotheses discussed? (2 pts)
11. Discussion: Limitations (4 pts possible)
Did the researchers discuss the limitations and strengths of the study? Briefly What were they? (3
Were there other limitations that you recognized? (1 pts)
12. Discussion: Implications/Recommendations (5 pts possible)
12.1 Do the conclusions accurately reflect the data? Briefly explain. (2 pts/)
Are the implications for practice clearly presented? Briefly Explain (1 pts)
Are suggestions for future research clearly presented? Briefly Explain (1 pts)
How do you see this research useful in HC? (1 pts)
List references ONLY IF other than the article being reviewed or the course text.
Quantitative 19SU
Evaluation of Printed Health Education Materials for Use by
Low-Education Families
Lesa Ryan, BS1 , M. Cynthia Logsdon, PhD, WHNP-BC, FAAN2 , Sarah McGill, BS3 , Reetta Stikes, MSN, RNC-NIC,
CLC4 , Barbara Senior, BSN, MBA, RN5 , Bridget Helinger, MSN, ARNP, ACNP-BC, CCRN6 , Beth Small, BSN, RN,
OCN7 , & Deborah Winders Davis, PhD8
1 Medical Student, University of Louisville, School of Medicine, Department of Pediatrics, Louisville, KY
2 Professor, University of Louisville, School of Nursing, and Associate Chief of Nursing for Research, University of Louisville Hospital/James Graham
Brown Cancer Center, Louisville, KY
3 Medical Student, University of Louisville, School of Medicine, Louisville, KY
4 Advanced Practice Educator, Center for Women and Infants, University of Louisville Hospital/James Graham Brown Cancer Center, Louisville, KY
5 Clinical Nurse Manager, Stroke ICU, University of Louisville Hospital/James Graham Brown Cancer Center, Louisville, KY
6 Advanced Practice RN, Stroke Services, University of Louisville Hospital/James Graham Brown Cancer Center, Louisville, KY
7 Registered Nurse Clinician, University of Louisville Hospital/James Graham Brown Cancer Center, Louisville, KY
8 Professor, University of Louisville, School of Medicine, Department of Pediatrics, Louisville, KY
Key words
Health literacy, patient education, health
communication, suitability of materials, reading
Dr. Deborah Winders Davis, 571 S. Floyd Street,
Suite 412, University of Louisville, Department
of Pediatrics, Child Development Unit, Louisville,
KY 40202. E-mail:
Accepted: January 22, 2014
doi: 10.1111/jnu.12076
Purpose: Millions of adults lack adequate reading skills and many written
patient education materials do not reflect national guidelines for readability
and suitability of materials, resulting in barriers to patients being partners in
their own health care. The purpose of this study was to evaluate commonly
used printed health materials for readability and suitability for patients with
limited general or health literacy skills, while providing easy recommendations
to health care providers for how to improve the materials.
Methods: Materials (N = 97) from three clinical areas that represented excellence in nursing care in our organization (stroke, cancer, and maternal-child)
were reviewed for a composite reading grade level and a Suitability Assessment
of Materials (SAM) score.
Results: Twenty-eight percent of the materials were at a 9th grade or higher
reading level, and only 23% were 5th grade or below. The SAM ratings for not
suitable, adequate, and superior were 11%, 58%, and 31%, respectively. Few
materials were superior on both scales. The SAM scale was easy to use and
required little training of reviewers to achieve interrater reliability.
Conclusions: Improving outcomes and reducing health disparities are increasingly important, and patients must be partners in their care for this to
occur. One step to increasing patient understanding of written instructions is
improving the quality of the materials in the instruction for all patients and
their families, especially those with limited literacy skills.
Clinical Relevance: Using materials that are written in a manner that facilitates the uptake and use of patient education content has great potential to
improve the ability of patients and families to be partners in care and to improve outcomes, especially for those patients and families with limited general
literacy or health literacy skills.
According to the National Adult Literacy Study, over 40
million adults are functionally illiterate and another 50
million have insufficient reading skills (Kirsch, Jungeblut,
Jenkins, & Kolstad, 2002). In addition to poor gen218
eral literacy skills, others have shown that 22% of
adults have only basic health literacy skills and 14% are
below basic levels of health literacy (Kutner, Greenberg,
Jin, & Paulsen, 2006). Poor health literacy skills have
Journal of Nursing Scholarship, 2014; 46:4, 218–228.

C 2014 Sigma Theta Tau International
Suitability and Readability of Materials
Ryan et al.
been associated with less positive health decision making
(James, Boyle, Bennett, & Bennett, 2012; Weiss, 1999),
adverse health outcomes (DeWalt, Berkman, Sheridan,
Lohr, & Pignone, 2004; Edwards, Wood, Davies, &
Edwards, 2012), increased emergency care utilization
(Omachi, Sarkar, Yelin, Blanc, & Katz, 2013), greater
risk for hospitalization (Baker, Parker, Williams, & Clark,
1998), higher annual healthcare costs (Baker et al., 1998;
Weiss, 1999, 2007), and lack of adherence to instructions
(Smith, Brice, & Lee, 2012). Individuals with chronic
health conditions who have limited health literacy have
greater severity in symptoms, have poorer health-related
quality of life, and feel more helpless than their more literate counterparts, even after controlling for income and
education (Omachi et al., 2013). Additionally, patients
with inadequate literacy and/or health literacy skills have
difficulty comprehending medical forms, insurance information, and prescription labels (Williams, Baker, Honig,
Lee, & Nowlan, 1998). The adverse outcomes, in part,
may be the result of patients misunderstanding or rejecting health instructions due to their lack of literacy skills
(Doak, Doak, & Root, 1996).
To compound the primary problem of low health literacy skills, individuals who lack literacy skills feel shame
and embarrassment, which has been shown to be an additional barrier in accessing health information because
they are not willing to admit that they have a problem
or are fearful in seeking help for their healthcare needs
(Parikh, Parker, Nurss, Baker, & Williams, 1996). Patients
who admitted to experiencing shame and having difficulty reading have often not told their spouses, children,
and/or healthcare providers for fear of being negatively
judged (Parikh et al., 1996). Research has also shown
that self-reported education level may not accurately reflect the reading level of the patient (Davis et al., 1994;
Mayeaux et al., 1995). In one study, participants had, on
average, an 11th grade education, but were reading at the
7th to 8th grade reading level (Davis et al., 1994). Care
must be taken not to assume reading level is the same
as educational attainment because educational standards
may differ from state to state and country to country.
In addition to the impact of health literacy on one’s
own health and healthcare utilization, there is evidence
to suggest that parent health literacy is associated with
child outcomes as well. For example, it has been shown
that children with asthma who have parents with low
literacy were more likely to visit the emergency room,
be hospitalized, and miss school more frequently than
children whose parents had higher levels of literacy
(DeWalt, Dilling, Rosenthal, & Pignone, 2007), and parents with higher health literacy have healthier children
and are more likely to breastfeed (Kaufman, Skipper,
Small, Terry, & McGrew, 2001).
Journal of Nursing Scholarship, 2014; 46:4, 218–228.

C 2014 Sigma Theta Tau International
Although there is a growing body of literature suggesting that health literacy is an important factor in the provision of healthcare services, healthcare professionals and
organizations have been slow to adapt materials to ensure
greater readability for all users. The average reading level
for most Americans is at the 8th or 9th grade level, with
one out of five adults reading at or below the 5th grade
level. Additionally, two out of five adults 65 or older
and inner-city minorities read at or below the 5th grade
level (Doak et al., 1996). Previous studies have reported
that as many as 53% to 90% of patient education materials are written at a 9th grade reading level or higher
(Freda, 2005; Hoffmann & McKenna, 2006; Shieh &
Hosei, 2008; Weintraub, Maliski, Fink, Choe, & Litwin,
2004). Other factors, in addition to reading level, contribute to the suitability of materials for those with limited education or literacy skills, including health literacy
(Doak et al., 1996).
Before interventions can be developed to improve
health outcomes for both children and adults and before
patients and families can be partners in their health care,
commonly distributed patient education materials must
be evaluated for appropriateness for low-education families. While there is a growing body of literature on health
literacy and reading level of materials, there is much variability in the findings. Contributing to the variability is
the way the materials are evaluated. Some researchers
present a single readability score, and others have used
both the Suitability of Materials (SAM) score and a readability score. The purpose of this study was to evaluate
commonly used printed health materials for readability
and suitability for patients with limited general or health
literacy skills, while providing easy recommendations to
healthcare providers for how to improve the materials.
Both the SAM score (Doak et al., 1996) and a reading
score that is a composite of seven commonly used tests
for readability were used as more comprehensive ways
to evaluate the materials. Having a more comprehensive
evaluation of the materials will provide needed information to support specific revisions of the materials for improved comprehension by a wider range of patient ability
levels and allows healthcare providers to develop materials that more specifically match the needs of their population.
Printed materials were evaluated from an academic
health sciences center in the southern United States. The
hospital is a tertiary center for the southwestern half
of the state. As a referral center, three areas that are
considered to be areas of excellence include cancer,
Suitability and Readability of Materials
stroke, and maternal-infant care. The medical center
serves a high percentage of minorities and underserved
clients. Approximately 19% of patients are indigent, 29%
receive Medicaid, over 40% are of a minority population, and 19% do not speak English. All printed materials for each of these units (total = 97) were included in
the evaluation as follows: 28 items from the Stroke Center, 27 items from the Cancer Center, and 42 items from
the Mother-Baby Unit. The sources of the materials varied from those obtained from national organizations such
as the American Heart Association, the American Cancer Society, the U.S. Department of Health and Human
Services, or the World Health Organization to institutiondeveloped materials or those that failed to identify the
source of the information.
Suitability of Materials
Each material was evaluated for suitability using the
SAM scale(Doak et al., 1996). The SAM scale was developed as a rigorous and quantifiable measure of attributes of printed materials that go beyond the assessment of reading level, but that influence readability
(Doak et al., 1996). Although originally developed for
use with printed materials, it has been successfully used
with other media (Doak et al., 1996). The authors developed the tool and validated it with input from healthcare professionals from several cultures and from faculty and students from two prestigious universities (one
school of public health and one school of medicine; Doak
et al., 1996). The tool has become the most cited method
for assessing patient education materials beyond reading level (Kang, Fields, Cornett, & Beck, 2005; Shieh &
Hosei, 2008; Wallace, Rogers, Turner, Keenum, & Weiss,
2006; Wallace, Turner, Ballard, Keenum, & Weiss, 2005;
Weintraub et al., 2004), and it is suggested for use by the
Food and Drug Administration, the National Institutes of
Health, and the National Library of Medicine. Suitability
is based on ratings on 22 items that comprise six factors,
which include content, literacy demand, graphics, layout
and type, learning stimulation and motivation, and cultural appropriateness (Table 1). Each item is scored 0
(not suitable), 1 (adequate), or 2 (superior), and a raw score
is calculated by adding the score for each item, when
appropriate, and dividing by the total number of items
scored out of a possible of 44. If an item is not applicable, no score is assigned and the denominator is adjusted
as needed. The resulting percentages are classified as follows: not suitable (0–39%); adequate (40%–69%); or superior (70%–100%).
A total of 97 materials were reviewed. A random sample of 35 materials was scored simultaneously and independently by two reviewers, and then scores were
Ryan et al.
compared to establish interrater reliability. The reviewers were a post-baccalaureate research assistant and a
second-year medical student. Any inconsistencies in scoring were discussed for clarification of the rules, and then
the materials were reevaluated. Reviewers had 100%
agreement on SAM overall classifications, with occasional
differences on individual item scores that did not impact overall classifications. Interrater reliability for itemby-item analysis for the two raters was K = .78 (p < .001; 95% confidence interval [0.74–0.82]). Two reviewers evaluated the materials. The SAM tool was easy to use, and interrater reliability was acceptable. Readability Readability was evaluated using the Text Readability Consensus Calculator, a readability software tool (available free at The program calculates
the number of sentences, words, syllables, and characters
in the text provided (Table 2). From those data, the readability assessment tool calculated readability using seven
different commonly used (Charbonneau, 2012; Colaco,
Svider, Agarwal, Eloy, & …
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