Educational comic book versus pamphlet for improvement of health literacy in older patients with type II diabetes mellitus: a randomised controlled trial

Abstract

Background. This study aimed to compare the efficacy of an educational comic book versus a pamphlet in improving the health literacy of older patients with type II diabetes mellitus (T2DM) in Hong Kong. Methods. Between August and October 2016, T2DM patients aged >50 years were recruited from the Risk Assessment and Management Clinic of Tsan Yuk Hospital. Their health literacy was assessed using the Chinese Health Literacy Scale for Diabetes - Multiple Choice Version (CHLSD-MC). Those with an imperfect health literacy score were randomised to the intervention or control group and to read an educational comic book or a pamphlet, respectively. Health literacy was reassessed immediately after the intervention. Results. A total of 165 patients were assessed. The mean CHLSD- MC score was 59.99 out of 68; health literacy was inadequate in 13.3% of patients. Among patients with an imperfect CHLSD-MC score, 88 agreed to participate and were randomised to the intervention (n=42) or control (n=46) group. After the intervention, the intervention group had a significantly higher absolute change in CHLSD-MC score (3.48 vs. 0.93, t(80)=3.28, p=0.002). Conclusion. An educational comic book is more effective than a pamphlet in improving the health literacy of older patients with T2DM in Hong Kong.

Headnote

ABSTRACT

Background. This study aimed to compare the efficacy of an educational comic book versus a pamphlet in improving the health literacy of older patients with type II diabetes mellitus (T2DM) in Hong Kong.

Methods. Between August and October 2016, T2DM patients aged >50 years were recruited from the Risk Assessment and Management Clinic of Tsan Yuk Hospital. Their health literacy was assessed using the Chinese Health Literacy Scale for Diabetes - Multiple Choice Version (CHLSD-MC). Those with an imperfect health literacy score were randomised to the intervention or control group and to read an educational comic book or a pamphlet, respectively. Health literacy was reassessed immediately after the intervention.

Results. A total of 165 patients were assessed. The mean CHLSD- MC score was 59.99 out of 68; health literacy was inadequate in 13.3% of patients. Among patients with an imperfect CHLSD-MC score, 88 agreed to participate and were randomised to the intervention (n=42) or control (n=46) group. After the intervention, the intervention group had a significantly higher absolute change in CHLSD-MC score (3.48 vs. 0.93, t(80)=3.28, p=0.002).

Conclusion. An educational comic book is more effective than a pamphlet in improving the health literacy of older patients with T2DM in Hong Kong.

Key words: Diabetes mellitus, type 2; Health literacy; Patient education handout

INTRODUCTION

In Hong Kong, the prevalence of type II diabetes mellitus (T2DM) is approximately 10% among the general population and 15% to 25% among those aged >50 years.1,2 In 2014, T2DM as the 10th most common cause of mortality accounted for over HK$2 billion in annual healthcare cost.1,2 Those aged >50 years are disproportionately affected by T2DM; 75% of the 2015 global diabetes-related health expenditure was for this age-group.3,4

Health literacy is defined as the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions.5 Lower health literacy is associated with higher medication errors and preventable hospitalisations, poorer management of chronic conditions, and higher mortality for elderly patients.5,6 In the United States, the prevalence of low health literacy among patients is estimated to be 26% to 68%.7 Because old age is a risk factor for inadequate health literacy, health literacy interventions for older diabetic patients may improve their health outcome and hence reduce the burden of diabetes on healthcare and social systems.7,8 Patients prefer simpler and more colourful publications over textbased materials,9,10 but such studies are few in Hong Kong.11 This study aimed to compare the efficacy of an educational comic book and a pamphlet in improving the health literacy of older patients with T2DM in Hong Kong.

methods

This study was approved by the Institutional Review Board of The University of Hong Kong and Hospital Authority Hong Kong West Cluster and conducted in compliance with the Declaration of Helsinki. Between August and October 2016, T2DM patients aged >50 years were recruited from the Risk Assessment and Management Clinic of Tsan Yuk Hospital. Their health literacy was assessed. Those with an imperfect health literacy score were randomised to the intervention or control group and given 5 minutes to read the educational material and 3 minutes to ask questions. Health literacy was reassessed immediately after the intervention.

For the intervention group, the education material was a 20-page comic book titied'...' designed by two university students. This comic book described a conversation between an elderly patient, her grandson, and her pharmacist about standard medication labels, correct timing of drug taking, and the correct way to store medications.

For the control group, the education material was a pamphlet titled '...' produced by the Hong Kong Department of Health. The pamphlet presented information on types of anti-diabetic medication, major medication sideeffects, correct timing of drug taking, necessary lifestyle modifications, and the proper way to store medications.

Health literacy was assessed using the validated Chinese Health Literacy Scale for DiabetesMultiple Choice Version (CHLSD-MC) that comprises remembering (18 items), understanding (4 items), applying (4 items), and analysing (4 items). The highest possible score is 68; a score of <52 is classified as inadequate health literacy. Cronbach's a for CHLSD-MC and its subscales are 0.884, 0.885, 0.667, 0.654, and 0.717, respectively.12 Intraclass correlation coefficient is 0.970.13

The intervention and control groups were compared using the Chi-squared test for categorical variables and independent sample t test for continuous variables. A p value of <0.05 was considered statistically significant. Absolute changes in CHLSDMC score for the two groups were compared using the independent sample t test.

results

A total of 165 patients were included. Their mean age was 64.71 years; 46.7% of patients were male. The mean CHLSD-MC score was 59.99 out of 68; health literacy was inadequate in 13.3% of patients (Table i).

Among patients with an imperfect CHLSD- MC score, 88 agreed to participate and were randomised to the intervention (n=42) or control (n=46) group. 82 patients were re-assessed with CHLSD-MC (Figure).

Before the intervention, the two groups were comparable in terms of age, gender, and CHLSDMC score (Table i). After the intervention, the intervention group had a significantly higher absolute change in CHLSD- MC score (3.48 vs. 0.93, t(80)=3.28, p=0.002) [Table 2].

discussion

Compared with the pamphlet, the comic book was more effective in improving the health literacy of older patients with T2DM. Inadequate health literacy in diabetic patients is associated with worse glycaemic control, higher rates of diabetes-related complications, and negative health consequences, especially among older adults.14-17

Improved health literacy can lead to better self- efficacy, health-related communication skills, and self-care behaviour, and thus health literacy is a target for patient education.18 Associations between health literacy and health outcomes are multifactorial, and alternative interventions are needed to enhance health literacy and medication compliance.19

The comic book used in this study fulfils the recommendations for health information dissemination by the US National Action Plan to Improve Health Literacy, namely picture-based instructions, less reliance on written communication, and user-centred design.5 Success in improving health literacy has been demonstrated by other forms of intervention, such as web-based programmes, telephone calls, group workshops, and personalised education sessions.20-24 Our comic book carries an extra advantage of being convenient, small, and easily distributable, and requires limited additional time and resources to implement. In addition, pictorial aids have been shown to promote information comprehension and recall, as humans have a cognitive preference for pictures over other forms of data presentation.25 Hence, comic books, rather than text-based pamphlets, should be adopted in patient education strategies.

There are a few limitations to this study. Patients were recruited from only one clinic in a relatively affluent area where the average health literacy is generally higher than in other regions. The higher baseline health literacy could have confounded the results by limiting the extent to which the patients' health literacy could be further improved, or by increasing the patients' ability to understand and apply the health information provided. Moreover, changes in health behaviours and diabetes outcomes could have been evaluated.

Future studies should include patients in multiple districts and assess concrete health behaviours (such as lifestyle modification and the ability to communicate health needs), and diabetes outcomes (such as haemoglobin A1c and diabetes-associated co-morbidities). Additional baseline characteristics such as cognitive function, education level, and social support should be obtained, as all of these can affect health literacy and behaviour. Cost-effectiveness should be calculated in order to provide quantifiable evidence on how the healthcare system may benefit from health education by comic books.

conclusion

An educational comic book is more effective than a pamphlet in improving the health literacy of older patients with T2DM in Hong Kong.

acknowledgements

We would like to thank Dr Coco Chen, Dr Michael Ni, Mr Eric Chan, and Dr Dana Vackova from the School of Public Health, The University of Hong Kong for their guidance through the Health Research Project programme, as well as Dr Jenny Wang, Ms KKYeung and the entire staff at the Risk Assessment and Management Clinic of Tsan Yuk Hospital for their support. We are grateful to Pui-Shan Kam and YinSai Chong for their design of the comic book, and to the Knowledge Exchange Fund of the University of Hong Kong 2015/16.

References

references

1. Centre for Health Protection, Hong Kong Department of Health. Diabetes mellitus. Available from: http://www.chp.gov.hk/en/ content/9/25/59.html. Accessed 21 June 2017.

2. McGhee S, Thomas GN, Schooling CM, Chau J, Wong LC. Economic burden of diabetes related to excess body weight in Hong Kong. Hong Kong Med J 2014;20(3 Suppl 3):5-7.

3. International Diabetes Federation. Diabetes atlas. 7th edition. Available from: http://www.diabetesatlas.org/. Accessed 21 June 2017.

4. Centre for Health Protection, Hong Kong Department of Health. Diabetes mellitus: a major public health challenge in the 21st century. Non-Commun Dis Watch 2012;5:1-9.

5. Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services. National action plan to improve health literacy. Available from: https://health. gov/communication/imtiatives/health-literacy-action-plan.asp. Accessed 21 June 2017.

6. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med 2011;155:97-107.

7. Paasche-Orlow MK, Parker RM, Gazmararian JA, NielsenBohlman LT, Rudd RR. The prevalence of limited health literacy. J Gen Intern Med 2005;20:175-84.

8. Baker DW, Gazmararian JA, Sudano J, Patterson M. The association between age and health literacy among elderly persons. J Gerontol B Psychol Sci Soc Sci 2000;55:S368-74.

9. Leung AY. Health literacy issues in diabetic care: how much do we care? Frontiers in Biomedical Research Symposium 2009.

10. Mayeaux EJ Jr, Murphy PW, Arnold C, Davis TC, Jackson RH, Sentell T. Improving patient education for patients with low literacy skills. Am Fam Physician 1996;53:205-11.

11. Leung AY. Seminar at the School of Social Work China Program and Immigrant Health Initiative, Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A. Health literacy and diabetes in Chinese populations. Available from: http://keck.usc. edu/en/Education/Academic_Department_and_Divisions/ Department_of_Preventive_Medicine/Research/Immigrant_ Health_Initiative/Past_Events/Angela_Leung.aspx. Accessed 17 November 2016.

12. Leung AY, Lou VW, Cheung MK, Chan SS, Chi I. Development and validation of Chinese Health Literacy Scale for Diabetes. J Clin Nurs 2013;22:2090-9.

13. Leung AY, Lau HF, Chau PH, Chan EW. Chinese Health Literacy Scale for Diabetes -multiple-choice version (CHLSD-MC): a validation study. J Clin Nurs 2015;24:2679-82.

14. Leung AY, Cheung MK, Chi I. Relationship among patients' perceived capacity for communication, health literacy, and diabetes self-care. J Health Commun 2014;19(Suppl 2):161-72.

15. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA 2002;288:475-82.

16. Souza JG, Apolinario D, Magaldi RM, Busse AL, Campora F, Jacob-Filho W. Functional health literacy and glycaemic control in older adults with type 2 diabetes: a cross-sectional study. BMJ Open 2014;4:e004180.

17. Tang YH, Pang SM, Chan MF, Yeung GS, Yeung VT. Health literacy, complication awareness, and diabetic control in patients with type 2 diabetes mellitus. JAdv Nurs 2008;62:74-83.

18. Bailey SC, Brega AG, Crutchfield TM, et al. Update on health literacy and diabetes. Diabetes Educ 2014;40:581-604.

19. Geboers B, Brainard JS, Loke YK, et al. The association of health literacy with adherence in older adults, and its role in interventions: a systematic meta-review. BMC Public Health 2015;15:903.

20. Muller I, Rowsell A, Stuart B, et al. Effects on engagement and health literacy outcomes of web-based materials promoting physical activity in people with diabetes: an international randomized trial. J Med Internet Res 2017;19:e21.

21. Long AF, Gambling T. Enhancing health literacy and behavioural change within a tele-care education and support intervention for people with type 2 diabetes. Health Expect 2012;15:267-82.

22. Rosal MC, Ockene IS, Restrepo A, et al. Randomized trial of a literacy-sensitive, culturally tailored diabetes self-management intervention for low-income Latinos: Latinos en control. Diabetes Care 2011;34:838-44.

23. Goeman D, Conway S, Norman R, et al. Optimising health literacy and access of service provision to community dwelling older people with diabetes receiving home nursing support. J Diabetes Res 2016;2016:2483263.

24. Cavanaugh K, Wallston KA, Gebretsadik T, et al. Addressing literacy and numeracy to improve diabetes care: two randomized controlled trials. Diabetes Care 2009;32:2149-55.

25. Katz MG, Kripalani S, Weiss BD. Use of pictorial aids in medication instructions: a review of the literature. Am J Health Syst Pharm 2006;63:2391-7.