Identifying educational needs

During initial consultation with clients, occupational therapists need to establish their clients’ educational needs. One of the most effective methods of doing this is by asking the client (Lorig 2001). In Vignette 11.1, Mr M identifies that he would like to be reminded of the movement precautions and wants to know how he will be able to return to performing self-care activities independently. For clinical situations where there is a large number of topics that clients may wish to receive information about (for example, in stroke rehabilitation), therapists may find the use of a checklist of topics useful as this ensures that no topics are overlooked. There are a number of possible sources that therapists can use when compiling a checklist. These include: the therapist’s and his/her colleagues’ experience with similar clients, a survey or focus group of clients, and published research studies which have explored the educational needs of the client group.

Therapists may also wish to use more formal methods of evaluating clients’ educational needs, such as questionnaires, scales or tests. One advantage of using a formal assessment is that it can be used as a baseline measurement and the assessment readministered after the educational intervention has been provided, as a way of evaluating the educational intervention. As highlighted at the beginning of this chapter, the aim of client education is to achieve more than just increasing a client’s knowledge. Consequently, therapists will typically need to assess more than just the informational needs of the client. Formal assessments can be useful ways of doing this. For example, a therapist may use a combination of a knowledge test, self-efficacy scale and health behaviour checklist with a client in order to comprehensively identify the client’s educational needs.

Although planning for an educational intervention commences with identification of a client’s educational needs, therapists need to be aware that these needs are not static. Clients’ needs will change over time, according to many variables such as the nature and stage of their medical condition and their readiness to change. Unless the therapist is only providing a one-off consultation to a client, a client’s educational needs should be continually re-evaluated while the therapist is working with the client.

Setting educational objectives

Following identification of a client’s educational needs, therapists should set objectives for the educational intervention. Objectives typically contain three elements: the behaviour or action that is to be achieved, the condition under which the behaviour/action will be achieved, and the extent (criterion) to which the behaviour/action should occur to consider the objective achieved (McKenna and Tooth 2006b). For Vignette 11.1, one of the objectives that the therapist sets for an educational intervention with Mr M may be as follows: ‘After one 10-minute session that demonstrates hip movement precautions and also verbally explains them (condition), Mr M will be able to demonstrate the hip movement precautions (behaviour) correctly and without prompting from the therapist (criterion)’. The therapist could also set objectives for the other identified educational needs such as being able to independently use long-handled assistive devices. Setting guidelines enables therapists to impartially evaluate if the objective has been met at the conclusion of an educational intervention.

Deciding when to provide the information

Providing appropriate education to clients at the appropriate time is critical and can greatly impact the effectiveness of the educational intervention. The extent of information that is provided at any point in time will vary according to many factors. Clients may only want to receive brief information that is relevant to their immediate concerns when they are seriously ill, recently admitted to hospital, or recently diagnosed with a health condition. Later, they may want to receive more detailed information. Anxiety can prevent clients from absorbing and processing information (Theis and Johnson 1995). Therapists should consider clients’ coping level and style each time that they provide information and be guided by clients’ readiness to digest information. The optimum time to provide information will vary according to each client, their circumstances and needs, and the type of information being provided. The comprehension and recall of information can be facilitated if the information is provided in more than one format (such as verbal and written), repeated over time, and opportunities for reinforcement and clarification are provided (Theis and Johnson 1995).

Choosing the format of the educational intervention

Through discussion with the client, the therapist needs to determine the client’s preferences regarding the format of the education and make decisions accordingly. Where possible, therapists should aim to use a combination of formats as this can often be more effective than using a single format (Theis and Johnson 1995). In addition to considering the client’s preferences, other factors that therapists should consider when deciding on format include: the educational resources available to the therapist; the type of content being provided; and the client’s cognitive abilities, educational level, impairments, preferred learning style (for example, visual or auditory), cultural background and primary language. Any impairment/s that clients may have (such as hearing, visual, cognitive or speech and language) can particularly influence therapists’ choice of format as these impairments impact on how clients are able to process information. There are a range of strategies that therapists can use to facilitate communication with clients who have one or more of these impairments and further reading related to strategies specific to each impairment is recommended (refer to Further Reading section at the end of this chapter for details).

Although verbal education is the most frequently used format, Vignette 11.1 highlights one of the potential difficulties associated with verbal education which is that people frequently forget what they are told (Kitching 1990). It has been estimated that most people remember less than a quarter of what they have been told (Boundouki et al 2004). Consequently, verbal education should ideally be accompanied by written information that supplements or reinforces the main points that were made verbally (Hill 1997). The reinforcement that is provided by written materials can have a positive impact on the effectiveness of the educational intervention (Theis and Johnson 1995).

Written materials have a number of advantages such as: message consistency, reusability, portability, flexibility of delivery, permanence of information and they are economical to produce and update. In a client focus group that explored education, Tang and Newcomb (1998) found that clients sought answers to their questions at the time they formulate their questions. This usually occurred after the client had seen the health professional, not during the encounter. To some extent, written materials may be able to assist clients in answering the questions that occur when they are not interacting with a health professional. A further benefit of written materials is that clients can choose the level and amount of information that best suits them as their level of coping changes (Weinman 1990). Prior to deciding to use written materials with a client, the therapist needs to consider the factors listed earlier, such as the client’s cognitive abilities, primary language, vision and reading ability. If a therapist chooses to proceed and use written materials with a client, it is essential that appropriate attention is given to the readability and design of the written materials.

Assessing clients’ literacy levels

Prior to making a decision to provide a client with written information, therapists may wish to assess his/her literacy level. This can also provide therapists with information about the type and style of written information they should use with the client and enables therapists to alter their educational intervention according to the client’s literacy level (Weiss et al 1995). Therapists should be aware that people with poor literacy often use a range of strategies to hide literacy problems (Weiss et al 1995) and are often reluctant to ask questions so as not to appear ignorant (Wilson and McLemore 1997). Although asking about a client’s education level may provide the therapist with some information about the person’s reading ability, reading skill has not consistently been found to be dependent on educational attainment (Weiss et al 1995). Therefore, therapists should consider also assessing a client’s reading ability formally (Weiss et al 1995, Wilson and McLemore 1997), using one of the published tests that have been designed for this purpose. Commonly used tests include: the Rapid Estimate of Adult Literacy in Medicine (REALM) (Murphy et al 1993), the Test of Functional Health Literacy in Adults (TOFHLA) (Parker et al 1995), and the Medical Achievement Reading Test (MART) (Hanson-Divers 1997). All of these tests evaluate a client’s ability to understand medical terminology and are quick and straightforward to administer and score.

Readability of written materials

The reading level, or readability, of a written material refers to how easy it is to read. Written materials should be written simply, at the lowest level that conveys the information accurately (Hoffmann and Worrall 2004). Unfortunately, it is quite common for health education materials to be written at a reading level that is higher than the reading ability of the majority of the clients who received the materials (Sarma et al 1995, Beaver and Luker 1997, Griffin et al 2006, Hoffmann and McKenna 2006a).

If the reading level of the intended recipients of the material is known (see previous section for how to assess this), the reading level of the material should be two to four grades lower than the average reading level of recipients (Boyd 1987). If the reading level is unknown, a 5^th–6^th grade reading level (typically equivalent to 10–11 years of age in the Australian education system) is recommended (Doak et al 1996, Weiss et al 1998).

There are a number of readability formulas that allow the calculation of an estimate of the reading grade level of the material. Readability formulas are multiple regression equations and usually involve a calculation of one or more of: average word length in syllables, average sentence length in words, proportion of common words used, proportion of words with three or more syllables, and proportion of words which are monosyllabic (Ley and Florio 1996). Two well-known readability formulas are the SMOG (McLaughlin 1969) and the Flesch Reading Ease formula (Flesch 1948). The latter is available through some word processing programs such as Microsoft Word.

The SMOG is fast and simple to use, widely used in health research, and has been recommended as one of the best readability formulas for assessing health education materials (Meade and Smith, 1991). The SMOG readability formula calculates readability using the number of long words, defined as words of three or more syllables, in 30 sentences (McLaughlin 1969). In the SMOG, 30 sentences are selected from the material that is to be assessed – 10 consecutive sentences from near the beginning, 10 consecutive from the middle and 10 from the end of the written material. For this purpose, a sentence is any string of words punctuated by a period, an exclamation mark or a question mark. From the 30 sentences, words of three or more syllables are counted, including repetitions. From the word count, grade levels are then obtained by using the SMOG conversion table (most easily obtained from the Internet) or by determining the nearest perfect square root of the total number of words of three or more syllables and then adding a constant of 3 to the square root. For example:

In this example, the grade level of the material is 11 (typically equivalent to approximately 16–17 years of age in the Australian education system).

Design of written materials

Readability is only one element that contributes to the appropriateness of written health education materials. When designing new written materials or evaluating existing materials, there are a number of features in addition to readability that should be considered. Appropriate written health education materials contain content and design features that are designed to maximize the effectiveness of the written material. Ley (1988) summarised this issue simply by noting that for written information to be effective, it needs to be noticed, read, understood, believed and remembered.

When considering the content and design features that should be used in written health education materials, the following categorisation system can be a way of grouping the features: content, language, organisation, layout and typography, illustrations, and learning and motivation (Doak et al 1996). After reviewing literature concerning the design of written health education materials, Hoffmann and Worrall (2004) compiled a list of recommended content and design features that should be followed when designing written materials. The features are shown in Box 11.1. There are checklists available that therapists can use to evaluate the suitability of written materials that they have developed or those that have come from other sources and they are considering using them. Two of these checklists are the Suitability of Assessment of Materials (SAM) (Doak et al 1996) and a checklist of content and design characteristics that was developed by Paul et al (1997).

Adult learning theory

Vignette 11.1 involving Mr M is a useful case study to illustrate one of the theories, namely the Adult Learning Theory, that occupational therapists should be aware of and where possible, use to guide their provision of educational interventions to adults. Even paediatric occupational therapists need to provide education to adults; typically those who are significant in the child’s life, such as their parents and teachers. The central premise of the Adult Learning Theory is that the learning process of adults differs to children and for successful adult learning, adherence to certain principles is necessary. The key principles are described below, along with some of the implications for practice:

Transtheoretical model

Occupational therapists often provide clients with education where the emphasis is on providing education that will enable clients to make longer-term behavioural or lifestyle changes. In addition to making decisions about the practical considerations of providing an educational intervention (such as educational needs, format and timing), there are other decisions that the therapist needs to make when the education aims to encouragethe client to make lifestyle changes. The occupational therapist needs to establish how ready the client is to change as this will subsequently alter the educational intervention. The transtheoretical model can be a useful guide for therapists when planning an educational intervention, particularly when the ultimate aim of the education is behaviour change.

The transtheoretical model considers the transition points in behaviour change and the underlying factors that facilitate change from one stage to another (Prohaska and Lorig 2001). According to the transtheoretical model, change is a process that consists of six discrete stages and individuals move through these stages, although not necessarily in a linear fashion, as they adopt a behaviour (Prochaska et al 1992). Another element of this model is the process of change component, which states that there are specific activities that individuals use to progress through the stages (Prochaska et al 1992). The six stages, along with some strategies (Prochaska et al 1992, Neufeld 2006) that can be used to assist clients to move through the stages, are listed below.

In the case of Mr S, he is currently aware that he needs to make changes to his lifestyle in order to improve his health and wellbeing and to reduce his risk of subsequent cardiac events. Mr S indicated to the therapist that he is interested in starting to make changes straightaway but that he is not sure how he should go about doing this and what he should do first. Part of the therapist’s role with Mr S would be to collaboratively decide on which behaviour he would like to target first (e.g. stopping smoking, losing weight or exercising regularly), discuss the incremental steps that are involved in achieving the target behaviour, and convert each of those steps into specific and measurable goals.

Partnerships with clients

The case study with Mr S highlights the fact that educational interventions should be a collaborative partnership between the therapist and client and that educational interventions should be designed so that client participation is facilitated. The principle of collaborative practice and active participation by clients in their health care is also at the heart of client-centred care (Law and Mills 1998), which is a guiding philosophy of modern occupational therapy practice.

Historically, clients have had a passive role where they have been provided with only the information that the health professional thinks they need to know (Coulter 1997). However, over recent years there has been growing recognition of the need for clients to be active partners in their own learning. There are now various models of client–health professional relations that promote the active involvement of clients in their care, such as the active participation model (Roter 1987), client-centred care model (Coulter 2002), the chronic care model (Bodenheimer et al 2002) and when the focus is on making decisions, the shared decision-making model (Coulter 2002).

Involving clients as active partners in managing their health is an important contributor to the empowerment of clients (Coulter et al 1998). Results of research studies suggest that by increasing clients’ sense of control and participation in medical care, they may be more motivated to manage their illness and perform the desired healthy behaviours, which may in turn lead to better outcomes (Greenfield et al 1988, Wyatt 1999). To become empowered and active participants in their care, clients need to be provided with information that they can use to manage their health. Without appropriate information, they cannot make informed decisions (Coulter 2002). However, establishing a client–therapist partnership requires more than just the provision of education that is tailored to the client’s needs. It also involves a collaborative, two-way relationship between the therapist and client, where the client’s beliefs, prior experiences, knowledge and preferences for receiving education contribute to the relationship, in addition to the therapist’s expertise (McKenna and Tooth 2006a). It is important to note that while the above section has focused on the importance of actively involving clients in their own care, not all clients may desire this level of involvement and some may prefer a more passive role. This is a legitimate choice that should be respected (Coulter 2002). However the opportunity to be actively involved should be available for all who want to take it (Tones and Tilford 1994).

Health Belief Model

In addition to the Transtheoretical Model, there is another model that occupational therapists may find useful when planning educational interventions, particularly those where the aim is behaviour change. According to the Health Belief Model (Becker 1974, Glanz et al 2002), individuals are more likely to change their behaviour if they believe that:

Therapists can provide information that specifically targets each of the four main components of this model. In the case of Mr S, he has already experienced a myocardial infarction and was very unwell in hospital for a number of days as a result. He has therefore already experienced events which have provided him with evidence of his susceptibility and the seriousness of the condition. As a result of the education that he received while in hospital, he is also aware of the benefits of making lifestyle changes. However, he is uncertain as to whether the benefits will outweigh the barriers and costs of making the changes. As part of her role, Mr S’s therapist could provide him with an action plan that contains specific how-to information, discuss potential barriers to implementation of the action plan, and in conjunction with Mr S, brainstorm solutions to overcome or cope with these barriers. If Mr S then decides that the benefits of taking action outweigh the tangible and psychological costs of taking action, it is likely that he may undertake the desired behaviour changes.

Self-efficacy

When clients have the necessary knowledge to undertake behaviour change, yet they do not change their behaviour, as is the case with Mrs C, it may be that their self-efficacy is low. Self-efficacy refers to an individual’s judgement of his or her ability to perform an action to reach a desired goal (Bandura 1986). Because one of the goals of health education is behaviour change, self-efficacy has an important role to play in health education. Therapists should be cognisant of the important role of self-efficacy and where possible, should evaluate clients’ self-efficacy (see section below on evaluating outcomes).

According to self-efficacy theory, a person is more likely to perform a particular behaviour if engaging in that behaviour is expected to result in desired outcomes (Bandura 1986). Even if individuals recognise the value in changing their behaviour, they also need to develop the confidence to carry out the behaviour prior to attempting the behaviour (Bandura 1986). Self-efficacy has been found to be a major determinant in the initiation and maintenance of behavioural change (Strecher et al 1986, Bandura 1997). Self-efficacy influences the amount of effort that an individual will put into a task and the length of time that he or she will persevere with the task in the face of obstacles (Bandura 1977). According to self-efficacy theory, self-efficacy can influence the acquisition of new behaviours, inhibition of existing behaviours and disinhibition of behaviours (Bandura 1977). It has been demonstrated that self-efficacy can be enhanced through education and that higher self-efficacy is related to successful attempts at behaviour change and improved health status (Lorig et al 1989, Clark et al 1992).

Therapists should realise that self-efficacy refers to specific behaviours in particular situations (Bandura 1977). It is not a global trait or personality characteristic and unlike personality characteristics which are difficult to alter, self-efficacy is malleable and able to be altered (Lorig and Holman 1993). When a therapist is attempting to alter self-efficacy, using the strategies described below, it is important that the therapist is specific about the change sought, as self-efficacy is specific to each behaviour (Glanz et al 2002). There are a number of strategies that therapists can use to enhance a client’s self-efficacy (Strecher et al 1986, Prohaska and Lorig 2001), such as:

Additional formats for providing education

The case of Mrs C is a good example of how therapists may find formats other than verbal and written information valuable when providing educational interventions. For example, the use of demonstration, in addition to written and verbal information, when educating Mrs C about exercises, would be invaluable. The use of video cassettes or digital video discs (DVDs) that contain educational material can be useful, particularly when the education involves demonstrations, such as of movements, techniques, exercises or activities. For example, a DVD that demonstrates how to carry-out joint-protection and energy-conservation techniques while performing self-care and household activities may be useful to provide to Mrs C as it will reinforce information that has already been provided face-to-face by the therapist. By providing her with a DVD, Mrs C can review the information as many times as needed and at any time that she needs to. DVDs can also be useful when the topic being covered requires graphics to more effectively explain the content. Video presentation of information caters to clients with auditory learning styles, as well as those with visual learning styles and can assist clients who have low functional health literacy or English as a second language to understand the content being conveyed. Audio, video and written materials all have the added advantage that clients can share them with their family members, so that even if family were not present when the therapist was providing the information, they can still receive the information.

Another educational format that can be useful for supplementing and/or reinforcing information that is provided by therapists is computer-based materials. There are a number of ways in which computer programs can be used as an educational intervention, such as providing clients with interactive information (see for example, Stromberg et al 2002), helping clients to make health-related decisions (see for example, Hochlehnert et al 2006), or providing clients with tailored printed information that is customised according to their informational and visual needs (see for example, Hoffmann et al 2004). Although it depends on the features of the software being used, there can be advantages to using computer programs to provide information such as: they can enable clients to interact with the information, view it at their own pace, and view only information that is relevant to them, they often contain graphics that clients can interact with and this can assist with understanding the information, learning tools such as knowledge quizzes can be incorporated into them, and some computer programs enable clients to print out the information that they have viewed on screen, which therefore provides them with a resource that they can refer back to at any time. Computer programs should be designed so that they are user-friendly and able to be operated by individuals who do not have computer experience. A recent systematic review of computer-based programs for people with coronary heart disease found that the programs were effective in increasing patients’ knowledge and that they were generally well accepted by patients (Beranova and Sykes 2007).

In addition to computer-based programs, the Internet is also influencing the provision of education to clients. Health information is one of the most frequently searched topics on the Internet (McMullan 2006). Clients who wish to be active consumers of health information will have a need to seek out their own information either before and/or after they have seen their therapist (McMullan 2006). Therapists may find that clients will come to them with information that they have found on the Internet and wish to discuss. Therapists need to be aware that ‘Internet-informed’ clients will affect the traditional therapist–client relationship, and therapists should acknowledge clients’ search for information, answer questions they have about information that they have found, and assist by directing them to reliable and accurate Internet sites (McMullan 2006).

Evaluating the outcome of educational interventions

Although therapists are accustomed to measuring outcomes and evaluating the effectiveness of interventions that they provide, they often do not apply the same process to educational interventions. Therapists should evaluate the outcome of any educational intervention that they provide, as they would after providing any other intervention, to determine whether the education had the intended effect and whether the stated objectives have been met. This information enables therapists to decide whether further education or reinforcement of the content is needed and whether the objectives, content and/or delivery methods of subsequent educational interventions should be altered to improve effectiveness (Hoffmann and McKenna 2006b).

The evaluation can be done either informally or formally, depending on factors such as the objectives of the educational intervention, the purpose of the evaluation, and the time and resources available. Methods of informal evaluation include seeking feedback from clients, ascertaining if they have understood the information that the therapist has provided to them, if their informational needs have been met, and if they have any unanswered questions.

In the case of Mrs C, an example of an informal evaluation would be asking Mrs C to correctly demonstrate the joint protection techniques that she was taught to use when doing household activities.

Formal evaluation typically requires administration of formal outcome measures and therapists must decide which outcome/s they will measure, which outcome measure/s they will choose, and when and how the outcome measure will be administered. Decisions about which outcome/s to measure should be guided by the objectives of the educational intervention. As one of the objectives in Vignette 11.3 was to improve Mrs C’s self-efficacy for incorporating joint protection techniques into her daily routine, a self-efficacy instrument would be an appropriate outcome measure.

Decisions about which outcome measures/s to use will depend on whether there is an existing outcome measure that will adequately measure what the therapist needs to. There are many published health education measures (such as measures of knowledge for various conditions, satisfaction, self-efficacy, health behaviour, emotional health and quality of life) and many of these are freely available. The Redman (2003) resource that is listed in the Further Reading section at the end of this chapter overviews many of the published health education measurement tools. However, for many of the educational interventions that are provided by occupational therapists, an existing outcome measure will not exist. In this case, therapists will need to adapt an existing outcome measure or create their own. There are some general guidelines to follow when adapting or creating outcome measures and these are described in the Hoffmann and McKenna (2006b) reference that is listed in the Further Reading section at the end of this chapter.

After deciding which outcome measure/s to use, therapists also need to decide when the measure/s will be administered. Decisions about timing will be guided by the original objectives that were set for the educational intervention. For example, for educational interventions that had the objective of improving knowledge it is appropriate to evaluate them shortly after, such as on the same day the education has been provided, whereas it may be more appropriate to evaluate an educational intervention that aimed to change behaviour at a later time, such as a number of weeks after the intervention, so that clients have the chance to implement what they learnt. An advantage of formal evaluation is that therapists can readminister the same formal assessment that was used earlier when they were establishing clients’ educational needs, and then compare changes in client’s performance on the assessment (a pre-test post-test approach) that likely occurred as a result of participating in the educational intervention. Because the same outcome measure may be used at both the beginning and end of an educational intervention, when initially planning an educational intervention, therapists should also plan how they are going to evaluate the intervention.

Before proceeding with the evaluation, therapists also need to decide how it will be administered. There are many available methods and choice will depend on factors such as the information sought, the clients’ needs and abilities, and the time and resources available (Hoffmann and McKenna 2006b). Use of a combination of methods is often most appropriate. Some of the most common methods of measuring outcomes include observation, interview, client self-report, open-ended questioning, questionnaires, scales, tests and diaries (Hoffmann and McKenna 2006b).