By Rebecca S. Sudore, M.D., and Gloria Mayer, R.N., Ed. D.
Studying
Communications
Effectiveness
Researchers at
SFGH-UCSF had
identified many
patients with
limited literacy
skills and had been
developing tools to
allow them to better
understand the
medical system. As a
clear need arose to
help patients
understand their
health care choices
at the end-of-life,
researchers at
SFGH-UCSF decided
not only to design
an easy to read
advance health care
directive, but also
to test its
efficacy. To
do this, the medical
center, in
cooperation with the
San Francisco
Department of
Health, conducted a
study. Researchers
at SFGH-UCSF
conducted a
randomized trial to
determine whether an
advance directive
written at a fifth
grade reading level
and containing
graphics that
explain the text
would be associated
with higher rates of
patient
acceptability and
self-efficacy with
treatment decisions
when compared to a
standard California
Advance Health Care
Directive form.
Study patients were
randomly assigned to
review and attempt
to complete either
the standard
California Advance
Directive form
(AD-Standard) or an
advance directive
(Easy-AD) written at
a fifth grade
reading level that
contained culturally
appropriate graphics
and the same legal
content as the
AD-Standard.
Acceptability with
the form,
self-efficacy about
treatment decisions,
and comprehension of
health care choices
were then measured.
After completing
this assessment,
subjects in each
group then reviewed
the alternative form
and reported which
form they
preferred.
Study
participants
randomized to the
Easy-AD form
reported higher
acceptability over
all as compared to
the Standard Advance
Directive, rating
the Easy-AD easier
to complete (80% vs.
62%) and easier to
understand (83% vs.
58%).
Participants
randomized to the
Easy-AD form were
also more likely to
report greater
self-efficacy with
treatment decisions,
reporting that the
form made it easier
to choose desired
medical care (84%
vs. 66%) and that
they had confidence
in making treatment
decisions (92% vs.
79%) as compared to
the Standard form.
Differences observed
between the Easy-AD
form and the
Standard form were
largest for those
with limited
literacy (e.g., easy
to complete [68% vs.
27%] and
Spanish-speakers,
e.g., easier to
complete [74% vs.
44%]). Subjects
randomized to the
Easy-AD form also
had over one and
one-half times
higher comprehension
scores concerning
treatment choices.
Finally, most
subjects (81%)
preferred the
Easy-AD form as
compared to the
Standard form.
The easier form was
overwhelmingly
preferred by
subjects with high
or low literacy and
those who were both
English and Spanish
speakers. Most
participants in the
study were older
(mean age 61), half
were women (53%),
three-fourths were
non-white, one-third
were
Spanish-speaking,
and forty percent
had limited literacy
skills.
This study
concluded that the
easier advance
directive form was
associated with
greater patient
acceptability,
self-efficacy with
treatment decision,
and comprehension,
particularly for
patients with
literacy and
language barriers.
However, regardless
of literacy or
language, the easier
form was preferred
by all participants.
