Communication prostheses and behavioral alignment in hospital leaflets
Paulo Roberto Vasconcellos-Silva; Francisco Javier Uribe Rivera; Brani Rozemberg
Escola Nacional de Saúde Pública, Fundação Oswaldo Cruz. Rio de Janeiro, RJ, Brazil
Review was made of publications that describe experience with printed material distributed to the lay public in hospital institutions. From the 146 leaflets examined, those aimed at professionals or disabled people, thus leaving 75 papers that illustrate the present pattern for the rationality behind the production, use and evaluation of this type of resource. In a general manner, such leaflets invest in the power of ideal printed information to align behavior with the hospitals biomedical agenda. The underlying rationality that permeates them perceives the perfect information package as one that efficiently describes its technical content for the purpose of unidirectional persuasion, is up-to-date in relation to readability scales and embellished by graphic design, and emphasizes the priorities defined by the professionals. Such communication prostheses should be capable of electronic validation by means of software suitable for proportioning the doses to the subject matter. Information as a drug, cognitivism, the lack of research on message reception and the need for communicative action for the deconstruction of systems of closed thinking within the hospital environment have been discussed.
Keywords: Health education. Health promotion. Communication. Education department, hospital. Hospital communication systems. Communication barriers. Hospital-patient relation. Communications media. Patient Education. Communication programs. Interprofessional Relations.
In the field of public health, educational programs for healthcare promotion have resorted to a variety of strategies for increasing peoples personal sense of responsibility through the recognition of unhealthy lifestyles. In a similar way within the hospital environment, although the contexts considered are much more specific, such a perspective is intuitively recognized by the professional teams, who are faced with the need to meet the demand for information from patients regarding diagnostic and therapeutic procedures and their complications. Perhaps this tendency is due to deep-rooted reference to the positive teaching impact that such leaflets achieve in the school environment.
Although motivated by the objective of guiding and adapting behavior, or as a precaution against future legal questioning, the need to keep patients informed is widely recognized and practiced in a diversity of clinical situations. The low costs involved, as well as the popularization of leaflets edited on personal computers, have helped to establish the publication and reproduction of informative leaflets for patients. In the hospital environment, all this material is mixed in with the official leaflets created by public bodies for promoting healthcare campaigns.
In an earlier study, Rozemberg et al (2002) observed the motivations and opinions of healthcare professionals regarding the production of hospital leaflets and pointed out the lack of research prior to their production and the low or nonexistent investment in evaluation research, or in other words, research that would verify whether such messages were received by the public they were destined for. In the present work, we have expanded our observations into the format of a critical and systematic review of publications that have sought to study the process of production and utilization of guidance leaflets for patients and the general population, as well as the measured and perceived effects.
The publications that make up the present review were collected from an extensive database (MedLine), through the use of the search term: information leaflets. The publications selected were those that gave a more detailed description of experience with printed material distributed in healthcare institutions. Many studies were not selected because they were considered to be redundant in relation to others with a greater degree of detail. Editorials and letters were also excluded, as were reports describing experience with the process of compiling leaflets that did not, however, add any type of empirical evaluation. The information search was limited to patient information leaflets (PIL) aimed at the lay public, and those related to professional training, information or updating were excluded. Studies on communication with patients with cognitive disorders or any other type of disability were excluded, since that topic, which is more specific and technically complex, deviates from the theme that was being pursued. An initial list of 146 studies was drawn up, to which the inclusion and exclusion criteria described above were applied. In this way, 75 articles were selected that illustrate the present pattern for the rationality behind the production, use and evaluation of this type of resource.
The intention of the present study was to put forward a second-order analysis that took as its starting point the primary analyses performed by healthcare professionals in their professional environment and context. Among the description of successes and failures in the field of communications between patients and professionals, studies have been included that took up the matter of guidance material produced as a safeguard against possible judicial intervention when such material was accepted only as educational practices. Informed consent leaflets, although without educational emphasis, have been included since they illustrate with interesting examples the guiding rationality for the production, utilization and evaluation of leaflets as a resource for attaining certain objective prioritized by the biomedical agenda (behavioral changes in the fields of prevention, diagnosis, therapy and adherence or consent in relation to experimental practices).
STUDIES ON THE EFFICACY OF LEAFLETS IN THE FIELD OF HEALTHCARE
A study organized by the Cochrane Foundation (Freemantle et al, 2000) has reviewed work that described the use of informative leaflets and their influence on the behavior of professionals and patients. This study was considered to be relevant, although it brings out more doubts than clarifications, given that it provides a synthesis of the concerns about a type of activity that is widely utilized in current practice in healthcare services and campaigns throughout the world. Its objective was to assess the effect of such material on the perceived impact of clinical evolution. Eleven studies were included (involving 1848 doctors and their patients), which compared the intervention of informative leaflets with control groups. Interventions powered by personal contacts (speeches, focal group meetings and workshops) were also included. The author concluded that, when compared with control groups, the results triggered by printed material were insignificant and had little practical importance and uncertain clinical relevance, even accepting the limitations on the evaluation of primary sources. The additional impact caused by other information transfer strategies (speeches and workshops) was considered small, although the role of educational visits and the influence of opinion-formers merited highlighting and were considered to have probable value. Although recognizing that the use of leaflets is an economically accessible practice, the author questioned the idea that the mere transfer of information would be capable of interfering in behavior and decisively modifying the course of therapeutic action.
Arthur (1995) made a synthesis of these questions, recalling that notwithstanding the great investments there are few in-depth studies in relation to the significant volume of printed material for these purposes. Like other authors, he questioned the usefulness and applicability of this resource when not preceded by demand and understandability studies. This author finishes by stating that, since professionals consider it important to keep their patients informed by means of leaflets, the studies in the field ought to be more profound, for reasons that are as much economic as ethical.
Chung et al (2000) tried to correlate the low adherence to tests for early detection of mouth cancer to the scarcity and inadequacy of the printed material available, which was thought to be perpetuating ignorance of the matter. In making linear correlations between knowledge levels and behavioral changes, we run up against the reductionist bias that distances us from the complexity that surrounds the matter. One example that goes against this belief in the power of information over behavior is the study by Robertson & Minkler (1994) on knowledge of the risks related to skin cancer in the United States. In this, they gave evidence that 38% of the population that was aware of the risks of exposure to the sun were not using and had no intention of using protectors.
PRINTED INFORMATION DOES NOT MODIFY BEHAVIOR
The absence of direct correlation between information and changes in behavior has been well recognized since the pioneering studies by Paulo Freire (1977, 1983, 1988, 1997).It forms part of the common sense of critical educators who make use of backing from anthropological, sociological and psychological studies for broadening the knowledge of the wide range of subjective factors that are implicated in the construction of behavior. Such presuppositions appear to converge with the professional experience of some authors who have demonstrated reduced expectations in relation to the use of leaflets. Thus, a study organized by Murphy & Smith in 1993 regarding opinions on and ways of using printed material among different types of healthcare professionals in Cardiff, United Kingdom, concluded that they had low belief in the capacity of educational leaflets to generate healthy habits or modify the behavior of their public. The same can be stated about the power of printed information over clinical events, whether this is in the incidence of collateral effects from medications among groups advised by leaflets and control groups, as in Murphy & Smith (1993), or in the reduction of anxiety and attenuation of psychosexual problems after colposcopy, as in Howells (1999), or in the field of early detection of breast cancer by means of diagnostic tests, in which Drossaert et al (1996) did not find cognitive advantages in the utilization of printed material, not even with prior adjustment by other patients who had experience such procedures.
This disbelief appears to be reinforced by the superficial manner of dealing with the topic of healthcare leaflet assessment adopted by those who produce them. Fitzmaurice & Adams (2000), in a wide-ranging systematic review of leaflets on arterial hypertension in England, found several problems involving not only the question of text readability but also the legibility of the characters, the design and the visual language as a whole. They concluded that healthcare professionals ought to be more attentive and critical regarding the production and evaluation of this type of resource, so that good information is not lost when carried in inadequate formats. Murray (2001)considered that the printed material distributed to pregnant women regarding screening for Downs syndrome in England was usually of low quality with regard to its readability attributes and the omission of relevant subject matter. Dickson et al (2001) expanded their sampling field by studying the model prescribed by the European Commission for educational healthcare leaflets distributed in the European Union. They concluded by stating that the model prescribed was far too rigid and did not lead to the expected cognitive gains through failing to adequately clarify concepts that were considered to be substantive. In relation to printed leaflets distributed for the prevention of congenital toxoplasmosis in England, Newton & Hall (1995) found factual errors, recommendations for practices considered risky and insufficient minimum content to be able to construct concepts on the subject. Converging with this, an evaluation of breast cancer leaflets in Sydney, Australia, by Paul et al (1998) concluded that the cost-benefit relationship was not normally taken into account in the production of leaflets in their country, since the material was rarely assessed after it was ready.
PRINTED INFORMATION CONTRIBUTES TOWARDS THE MODIFICATION OF BEHAVIOR
Despite the description of many failures, the power of information to attenuate anxiety when imminently faced with invasive or painful processes has always been recognized, even if only intuitively by the teams. Jackson & Lindsay (1995) compared the effect of leaflets that brought up the subject of fear of the dentists waiting room with material that contained detailed information about dental procedures. Through the use of a questionnaire for assessing anxiety levels, they found more encouraging results among the patients who had access to the second group of leaflets. Murphy et al (1995) recognized the beneficial effects, in terms of attenuation of negative feelings and somatic effects, among patient caregivers who received informative kits with leaflets produced for this purpose. Tourigny (1998) added that printed information directed towards pediatric patients and their families may be useful in the preoperative period before minor surgery, and also categorized such initiatives as educational. In relation to healthcare promotion in the workplace, Harvey et al (2000) also showed optimism regarding the potential of the leaflets evaluated for modifying behavior. Likewise, Macfarlane et al (1997), observed a lower number of returns for repeat consultations after printed explanations among patients with chronic pulmonary diseases. Chung et al (1999) studied the influence of informative leaflets that attempted to reduce the consumption of benzodiazepines for prolonged periods, and found behavioral modifications in 25% of the patients (average reduction of 2.5 mg/day).
COGNITIVISM: RELATIONSHIP BETWEEN BEHAVIORAL ALIGNMENT AND KNOWLEDGE
It can be seen that, although apparently contradictory in results and conclusions, the key point among the studies that have assessed the value of leaflets is fundamentally cognitivist, centered on the matter of readability and presumed singleness of message for the comprehension and assimilation of the content. There are emblematic studies like that of Mant et al (1998), regarding the effects of informative leaflets distributed to patients who have suffered encephalic vascular events. After the distribution of the printed material, patients and their caregivers were evaluated by means of questionnaires and scored in relation to their cognitive gains and also their general satisfaction about the information made available and improvements in their quality of life. Despite recognizing limitations on their study, they concluded that there were only cognitive gains, without statistically relevant results regarding the other categories.
In one of the precursors to the cognitive evaluation of printed material on healthcare, Cole (1979) studied the readability of leaflets among 120 volunteers. Upon observing frequent difficulties in the comprehension of technical terminology that could be correlated with the participants socioeconomic level, he concluded that there was a need for glossaries with detailed explanations regarding technical terms. Similar results and conclusions have been obtained in other contexts, such as the evaluation of leaflets on oral hygiene by Newton & Hall (1995), toxoplasmosis (Newton, 1995)and asthma (Bauman, 1997).Mumford (1997), studying leaflets produced by specialized nurses, concluded by recognizing that there had been little progress in 40 years of research into this field, and questioning the role of readability scores in the assessment of printed educational material.
Gibbs et al (1990) involved 3410 patients in an evaluation of leaflets about the prescription of different types of medications. Although they found significant cognitive advances, they did not mention any differences in the incidence of collateral effects. On the other hand, Little et al (1998) obtained poor cognitive results from a statistical study of leaflets giving advice on questions regarding contraceptive medication. They concluded by recognizing that, although it is time-consuming to ask patients about what would be the most appropriate matters to include in such leaflets, an approach of this nature could produce worthwhile cognitive gains. In a subsequent study, Little et al (2001) made a statistically evaluation of the effect of leaflets about less serious diseases that were sent through the post, in relation to the demand for attention to these types of affections, and observed the same insignificant impact on demand. Glanz & Rudd (1990), assessing 38 leaflets on cholesterol control, concluded that the degree of vocabulary complexity was relatively high and there was a lack of information that was relevant to the clientele. The cognitivist premise of readability guided the linguistic study by Bjorn et al (1995) regarding the content matter for informed consent forms for joining clinical studies and another study by Petterson et al (1994) on the adequacy of educational leaflets on diabetes for the elderly in a teaching hospital in England. In the latter, 10% of the leaflets analyzed used inadequate vocabulary and 73% did not fulfill the minimum criteria of typeface legibility. The authors observed that even the leaflets produced by communications specialists often did not fulfil the minimum criteria of legibility and understandability, despite being simpler and more accessible, which could be an expression of inability in graphic and textual communication. Bernardini et al (2000)endorsed such priorities in describing the demand by patients for typographic, color, symbol and format modifications that they would prefer for printed information on medications. From 1,004 interviews, they pointed out the manifest difficulties both in the gathering and comprehension of relevant information (collateral effects, use during pregnancy, posology and contra-indications, among others). In their second work, Bernardini et al (2001) presented the results from questionnaires distributed with the objective of better defining the attributes that are considered to be indispensable. This revealed a clear demand for graphic features that make the information more easily available, as well as leaflets that are more concise and make their content more explicit. Maggs et al (1996) also appear to have been guided by a cognitive approach in describing a randomized double-blind study in which the power of information for modifying the clinical evolution of chronic diseases among patients in a rheumatology service was assessed. Even though significantly greater levels of knowledge were achieved in the group that received leaflets, in comparison with the control group (with or without complementary information furnished by the professionals), no significant differences in clinical evolution of the diseases took place between the groups. This demonstrated that, in that context, the information was unsuccessful in increasing the power of the arsenal of therapies available.
Expanding the concerns a little beyond the inadequacy of the vocabulary and consequent reading difficulties, Wilson (1996) also criticized the use of leaflets of poor ethnic-cultural adequacy. Less than 10% of the leaflets were considered to be sensitive to the cultural and ethnic differences of communities in Detroit, where this study was organized.
Richard et al (1999) were innovatory in studying the effect of different text and graphic styles in the generation of knowledge for attitude changes. To verify the relative weights of behavioral changes obtained from leaflets produced in humorous, alarmist or neutral (control) styles, they evaluated behavioral modification effects in relation to the prevention of melanoma (a type of skin cancer). They thus observed that leaflets with a humorous style were more efficient in leaving an impression, but inefficacious in fostering sufficient implantation of the content for triggering the intended changes, whereas the leaflets with an alarmist content were discarded by the readers. They concluded that the tone of the leaflets had little interference in attitude changes regarding risk factors, overexposure to the sun and self-examination of the skin. On this point, it is of interest to observe, as did Jones et al (2000), that it is not uncommon for professionals to keep to a stereotypical view of their patients in relation to the most attractive way of putting over the subject matter. The latter authors analyzed leaflets directed towards adolescents with asthma and concluded that doctors and their patients often disagreed in relation to selecting the format and content material regarding this disease. While pediatricians tended to choose messages with a humorous tone and language full of slang, in the belief that they would in this way reach their public more efficiently, the adolescents clearly expressed their desire for content that was rich in factual information, put forward in a sober but plentifully illustrated style.
Questioning the influence of cognitive differences in changes of habit, Sumner (1991) utilized software that adapted leaflet content according to the users declared level of education, by means of readability scales. He compared the results between a group that received electronically adapted material and a control group, and observed that there were no relevant differences in behavioral changes. The poor results obtained gave grounds for certainty regarding the insignificant bearing of the readability of the printed material on behavioral changes, although recognizing the importance of efforts towards text adaptation in this activity.
There are works that take up the matter of the lethal risks from cognitive lapses that are formed around gaps in professional interactions. Albarran & Bridger (1997) highlighted professionals incapability to explain to patients with recent infarct about the risks involved in the physical effort of intense sexual activity, thus emphasizing the need to develop printed leaflets with better explanations. Ward et al (1998) warned about the failure of leaflets to adequately explain to patients about the risks involved in azathioprine treatment for inflammatory intestinal diseases that could expose the team to the risks of judicial intervention.
A qualitative evaluation of educational material on cancer distributed by two American institutions, organized by Foltz & Sullivan (1999), pointed out the demand among patients for content related to emotions and Sex, which were absent from the leaflets but are matters characteristically accessible through personal contact. Four years earlier, Meredith et al (1995) conducted a study on deficiencies in leaflets distributed by 53 urologists in England to patients in the preoperative phase of prostatectomy. Among the 4,226 questionnaires answered by patients and 807 supplementary comments, the problems most frequently indicated related to the omission of relevant information on malignant transformation and Sex. Only one of the leaflets studied referred to the malignant potential of prostatic diseases, while 29% of the patients felt a lack of such information. Only six out of the 25 leaflets mentioned possible alterations in sensitivity during Sex (saying that there are no differences), while 35% of the patients complained that there was a reduction in sensitivity after the operation. The study concluded that, in addition to a lack of uniformity of form and content, the standards of printed information at that time did not meet patients demands in that field and context.
Humphris et al (1999) described three studies on leaflets about the prevention and early detection of mouth cancer, in which assessments were made of the production process, specific mechanisms for expert validation, readability studies and, finally, questionnaires in which the degree of knowledge acquired by the population that had access to the leaflets was tested. They concluded that statistical treatment involving reliability and validation tests, and also instruments for measuring the degree of knowledge after exposure to the educational leaflets, were essential in this type of activity. This example illustrates the superposition of a transmitted cognitivist bias over the educational demands perceived in this context. Priority is given to the dissemination of information, improvement in specific instruments for carrying the message, the need to systematically measure the impact on the comprehension and implantation of the subject matter, and other subsequent studies for validating the whole process. In a later work, Humphris et al (2001) made a linear correlation between informative content relating to the prevention of mouth cancer and its potential for modifying habits. Success in the validation questionnaires for the patient information leaflets (evaluation of cognitive attributes) was unequivocally considered to be a guarantee of behavioral changes.
INFORMATION AS A DRUG
Reflective reading of the studies that have shown the most positive results suggests that these were gathered in fields in which there were personal approaches that were more enriching. Even if leaflets were plentifully endowed with illustrations and were culturally adjusted and cognitively well implanted, they did not unequivocally attain the educational objectives that had been proposed for them (although we have to recognize that such attributes were rarely encountered fully among the works consulted). It can be seen that relational influence stemming from active interactions, on the other hand, gave rise to some valuable results. The mere fact that the text and graphics were comprehensible, with careful evaluation by specialists and using readability scores, was not a guarantee of the attitude changes desired. Professionals steeped in standards of instrument rationality in the field of healthcare education systematically confound communication dimensions (involving human interaction) with transmission dimensions that involve information technology, carried by either printed or electronic media. Sometimes the transmission tactic does not reach its objectives and fails in the statistical validation processes that it is subjected to (as in Sumner,1991 and Freemantle et al, 2000). In certain contexts it is not possible to advocate the absolute abolition of such tactics, or to prescribe them from such disappointing results. From this impasse, attempts to adapt the instrument used by means of questionnaires or software may emerge (as done by Sumner, 1991), or there may be proposals such as the downloading of documents from the internet to foster the dissemination of matters relating to sexually transmissible diseases indicated in Lau (1997).
At some moments, the instructional rationalityof these studies recalls the methodology for evaluating the efficacy of medications. Studies on drug absorption and their bioavailability (the proportion of the dose that becomes available in the plasma to cause effects at the target site) may be compared with the assessments of readability and adequacy. In the same way, the need for associations with other adjuvant agents that give power to the cognitive effect of the leaflets in question becomes a subject for research that recommends that use of databanks and multimedia resources for disseminating knowledge and, through this, promotes healthy changes in behavior in their respective contexts, as in Wise et al (1996), Street et al (1998), Luck et al (1999), Barkhordar et al (2000) and Graham et al (2000).
A discussion regarding the selection of subject matter and the prescriptive competence of doctors can be found in Kee (1996), in which doctors paternalistic tendencies in the choice of information considered pertinent is criticized. Other studies have gone into the question of the ideal information dose and its collateral effects. In this respect, Lamb et al (1994) highlighted some curious premises, such as the impression that the more informed the patient is, the more he will feel imaginary complications. Entwistle & Watt (1998) described similar concerns among members of a team providing healthcare information, when studying the distribution of leaflets on the early detection of prostate cancer. They indicated that some of the team showed reluctance in distributing the material because they believed that this type of information would trigger anxiety among those it was destined for. In the same way, Garrud et al (2001)found a belief among professionals that detailed information on the risk of laparoscopy would induce patients to give up on this type of procedure. By means of leaflets with different doses of information from the most generalized to the most detailed they observed that the latter did not interfere in increasing the degree of anxiety, nor did it influence whether patients gave up on submitting to the procedure. In Kruse et al (2000) we also find emphasis related to the dose of subject matter, and a concern regarding pharmaceutical forms. To evaluate the knowledge acquired and the changes in patients attitudes, they compared three formats for carrying information: leaflets, notebooks or booklets (with increasing levels of detailing in relation to the matter dealt with) and concluded, as did Garrud et al (2001), that the best results were gathered from the field of the most detailed information, carried via booklets. With the same perspective of absorptive competence Pratt et al (1957)observed that doctors generally overestimated patients capacity for information retention. Garden et al (1996) also devoted study to the ideal doses, through leaflets on anesthesia offered to patients before operations. To discover the appropriate quantity of information, they distributed leaflets with three levels of content: complete and detailed information; standard information; and the minimum content necessary. It is noteworthy that when the leaflets were distributed separately, patients showed themselves satisfied with the level of explanations offered, in a similar way for all categories. However, when they had access to the three types of leaflet, they began to consider the minimal discourse as insufficient and demanded material that previously they had not perceived to be absent.
Taking the reading of these works as a whole, we have obtained success in achieving behavioral alignments from large doses of good information to be adjusted in terms of posology, according to individual capabilities for assimilation. The study and recognition of ethnic, cognitive and cultural profiles would add complexity to the task of producing easily assimilated data, and this should lead to high bioavailability of useful information. In the production of this type of educational material, it is not uncommon to observe demands for substantive ingredients in the composition of the content. Non-relational formats that are poorly interactive as communication prostheses do not take into account the diversity of content and context types, especially those that deal with death, mutilation, pain and losses. Furthermore, blatant lapses indicate poorly satisfied demand for discussion regarding emotions and Sex, domains that are accessible when there are closer personal approaches.
ILLUMINISTS, ANTI-INTERACTIONIST AND PROTO-INTERACTIONIST
At this point it is of interest to observe that the majority of the work described above tends to characterize the activity of supplying patients with information in a discursive manner as an activity of secondary or complementary relevance to the therapeutic action. Thus, the transmission of content matter is consolidated as a persuasion tactic for facilitating specialist intervention and not an explanation for a harmonious decision. On the other hand, it is opportune to note an evolution in the studies described above that has not been connected up. The majority of the precursor work referred to the need to pass on information to patients as a purely cognitive challenge. This aspect, of illuminist nature, emphasizes the need for transmitting unambiguous standardized information, thus investing in readability studies.
Making use of scale and score instruments that just make explicit the cognitive differences, healthcare workers coming from different environments and methods of professional attention thus develop their communication deficiencies from which prostheses are derived that ignore the multivoiced nature of human communication. The ritual of information transmission is taken here to be a standard procedure in professional half-interaction, which wastes moments that would be suitable for interaction and mutual enrichment. As a result of these characteristics, we find anti-interactionist work that sees human contact as risky or in some other way disadvantageous in environments where there is the weight of extreme emotions, such as in the emergency rooms of large hospitals (Nelson, 1997). Whether as a substitute or complement for this interaction, the printed information is exhaustively dismantled and redefined in its attributes (with purposes taken to be educational), with an impact that is often weak. In these studies, the priority importance attributed to text structure (intelligibility and appropriateness of content) and graphic structure (legibility of the characters and print-quality graphic design) can be seen, with some attention to making the adaptations needed for the messages (age group, ethnic profile and level of education).
Some strategies with a relational approach are emphasized only as additional assistance in the task of transmitting the subject matter. Notwithstanding this, the evolution to which we referred above is hinted at in the appearance of work that is proto-interactionist but perceptive to the potential of personal relationships and discursive regarding behavioral modifications. Some work makes an effort to overcome the difficulties presented by readability, through supplementing the text information with personal contact. It is of interest to note that, although already concerned about relational matters, this movement also reaffirms a commitment towards cognitive enrichment as the main resource for behavior modification.
Mazur & Hickham (1994)stated that it is not the information load in its quantitative aspect that interferes in patients decisions and choices, but rather what they called the data explanation level (which we interpret as something close to an adaptation to the cultural, ethical, emotional and religious possibilities of the subjects). There is agreement between some studies like those organized by Schulman (1979), Stewart (1995) and Horowitz et al (1990) in stating that patients who feel they are participating in the decisions and choices in their treatment achieve greater therapeutic success rates. In Horowitz et al (1990), the patients with recent infarct who collaborated better in their adherence to the treatment had significantly lower mortality in comparison with those among whom such cooperation was not established.
One general tendency is the scarcity of reception studies subsequent to the implementation of the material. Although it cannot be categorized as a complete reception study, the study by Mottram & Reed (1997) deserves mention. This made a quantitative assessment of the relevance hierarchy of content regarding medications, comparing the views of different profession categories in relation to patients. Predictably, there was a fundamental difference in emphasis between the views of professionals and patients in their demands. Some rare studies express concern regarding the validation of content matter by those principally interested in it, involving them in the various stages of production and evaluation of the material (as in Kubba, 2000). Others concentrate, at the most, on evaluations made by the professional teams, as described by Zakrzewska et al (1997) and Batista-Miranda et al (1995).
Simpson et al (1999) described a prenatal HIV test program among groups of pregnant women submitted to various combinations of textual and verbal educational approaches (furnished by trained assistants). The best results (cognitive and behavioral) were observed in the groups coordinated by guides with positive leadership attitudes the influencers. Simpson finished by recognizing an efficacious behavioral type in the positive attitudes of some assistants in interacting with the pregnant women. IN the same way, this author recognized that the efficient transmission of content did not guarantee behavioral changes in this context. Seals & Keith (1997) also recognized positive influences in pharmacists interactions with prisoners in their attempts to influence them to adhere to anticonvulsive medication in prisons. Van Es et al (1998) perceived among adolescents with asthma that they preferred personal contact with the professionals rather than just receiving information through patient information leaflets. Peveler et al (1999) came to a similar conclusion in the field of adherence to treatment with tricyclic antidepressants, observing more significant results through consultations in comparison with simple distribution of leaflets.
Finally, there are authors like Schreiber (1997) who believe that information transmitted via a discursive route cannot be substituted, whereas others go beyond the mere intention to transmit (like Granitza, 1997) by reaffirming the ethical objectives of the discussion and explanation in the context of professional contacts mediated by leaflets.
Contrary to the important role held by educational leaflets in the school environment, in which prominent results are achieved and given their power through the fact that there is dialog in the relationship between teachers and students, such an impact has not been observed in the hospital environment. Leaflets of supposed informative character have repeatedly been produced and sent out as instruments voicing a monologue, in order to transmit information that has unilaterally been defined as relevant, without subsequent reception studies. Since they are conceived and produced as specialist and individual projects, the process of updating them, when this takes place, also takes into account the locally prioritized details of specialist nature. Such reduction into particles is characteristic of hospital organizations, as pointed out by Mintzberg (1995 and 1998). In a general manner, leaflets tend to rapidly become out-of-date and are finally forgotten in drawers and cupboards, as was observed by Fawdry (1994).
The proliferation of computers and printers, in association with the productivity targets that have shortened the duration of consultations, favors the proliferation of printed materials that end up amputating dialog and aborting relationships of trust. In this sense, the great professional autonomy that is fundamental to professional healthcare organizations is found in poorly interactive clinical contexts to be a facilitator for distancing.
Weak as communication prostheses, leaflets that are disconnected from personal approaches fail to influence those who they are destined for, who are mere receptors, neutralized in their culture, biography and subjectivity. Even so, Fawdry (1994) stated that such leaflets, although excessively technical, are read attentively by patients, even when without illustrations or other adornments. This interest was attributed to the anxiolytic function of information on procedures that are more invasive and involve high complexity and risks.
Review of the literature reveals that no strategies have been considered for implementing such methods through institutional projects that involve professionals from various specialties and motivate them to interact, in an effort to obtain communication with their patients. The perceived emphasis in these studies is centered on the process of producing unidirectional messages that are shorn of modulation and ambiguity, and essentially accepted as unquestionable because of their scientific grounding. In the same way, as stated by Brazilian authors in relation to national healthcare campaigns, such as Fausto-Neto (1995) and Araújo & Jordão (1995), it is rare to find reception studies that allow directions not considered by biomedical reasoning to be gathered, given that such reasoning is taken to be unambiguous and universal. This makes it difficult to have an accurate perception of the mechanisms for constructing the meanings, the authenticity of patients affirmations and their coherency with their internal experience, which is considered true by such subjects, as exemplified in the studies by Rozemberg et al (1994 and 1998).
Finally, some recent work such as Rozemberg et al (2002), Baillie (2000) and Dixon-Woods (2001) has perceived a biomedical discourse that is hegemonic and technicist, and subjacent to research on the production and evaluation of leaflets as a substitute for interactions between professionals and patients. It conceals a mechanistic communication model that is committed to a biomedical agenda that sees patients as passive individuals that are receptive to manipulation, thereby generating a need for anticipating the subjects of their queries and curtailing the need for dialog.
Baillie et al (2000) goes more deeply into this debate in an interesting way, through attributing the failures in the field of healthcare education to faulty explanation models that do not consider approaches with communicative action based on full human interaction with an interest in dialog. This author proposes a model based on critical dialog, extracted from the communicative action theory of Habermas (1987). An open communication process becomes essential, not only for penetrating barriers that are erected between groups, but also for exposing and identifying the interests from which each group structures its knowledge. In this sense, communicative action would assist in projects for deconstructing closed systems of thinking, by differentiating the objectives and corporate significance of a broader social interest.
In conclusion, in the hospital context, rational specialist action of instrumental monologue nature tends to fail in its project for influencing behavior, through not perceiving (or not having any way of instrumentally substituting) the need for establishing interpersonal relationships based on rules of mutual recognition that ensure active questioning and listening.
From a subliminal conceptual model that confounds the dissemination of information with full communication, leaflets are planned that will subsequently be selected by patients from displays placed in outpatient departments and the lobbies of hospitals with large population movements.
With regard to the assessment of the efficacy of such communication prostheses, as well as being taken from the context of experience, it is achieved by means of local measurements and yardsticks that provide little for comparisons and only make efforts to measure narrow aspects of a multifaceted play that cannot be dissociated from its environment.
In this context, it would be an interesting challenge to draw up ways of mobilizing organizational means that articulate work practices regarding active, critical, perceptive and flexible mental models within the heart of an organization that is in itself fragmented and without linkage to the means and the problems of its time. The insular structure of professional hospital organizations generates isolation and inability to communicate among the professionals themselves and with the patients. The outline of their communicative pseudo-action among themselves and with the outside world, with their instrumental and monologue nature, thus shows up an unnecessary and counterproductive distancing.
Albarran JW, Bridger S. Problems with providing education on resuming sexual activity after myocardium infarction: developing written information for patients. Intensive Crit Care Nurs. 1997;13:2-11.
Araújo I, Jordão E. Velhos dilemas, novos enfoques: uma contribuição para o debate sobre estudos de recepção. In: Pitta AMR, organizador. Saúde e comunicação: visibilidades e silêncios. São Paulo/ Rio de Janeiro: HUCITEC/ ABRASCO; 1995. p. 172-89.
Arthur VA. Written patient information: a review of the literature. J Adv Nurs 1995;21:1081-6.
Baillie L, Basset-Smith J, Broughton S. Using communicative action in the primary prevention of cancer. Health Educ Behav 2000;27:442-53.
Barkhordar A, Pollard D, Hobkirk JA. A comparison of written and multimedia material for informing patients about dental implants. Dent Update 2000;27:80-4.
Batista-Miranda JE, Darbey M, Kelly M, Bauer S. Entorno, informacion al paciente y organizacion en una Unidad de Urodinamia Pediatrica. Arch Esp Urol 1995;48:15-22.
Bauman A. The comprehensibility of asthma educational materials. Patient Educ Couns 1997;32(Supl 1):51-9.
Bernardini C, Ambrogi V, Perioli LC, Tirolli MC, Fardella G. Comprehensibility of the package leaflets of all medicinal products for human use: a questionnaire survey about the use of symbols and pictograms. Pharmacol Res 2000;41:679-88.
Bernardini C, Ambrogi V, Fardella G, Periolo L, Gandolini G. How to improve the readability of the patient package leaflet: a survey on the use of colour, print size and layout. Pharmacol Res 2001;43:437-44.
Bjorn E, Rossel P, Holm S. Can the written information to research subjects be improved? An empirical study. J Med Ethics 1999;25:263-7.
Chung KF, Cheung RC, Tam JW. Long-term benzodiazepine users- characteristics, views and effectiveness of benzodiazepine reduction information leaflet. Singapore Med J 1999;40:138-43.
Chung V, Horowitz AM, Canto MT, Siriphant P. Oral cancer educational materials for the general public:1998. J Public Health Dent 2000;60:49-52.
Cole R. The understanding of medical terminology used in printed health education materials. Health Educ J 1979;38:111-21.
Dickson D, Raynor DK, Duman M. Patient information leaflets for medicines: using consumer testing to determine the most effective design. Patient Educ Couns 2001;43:147-59.
Dixon-Woods M. Writing wrongs? An analysis of published discourses about the use of patient information leaflets. Soc Sci Med 2001; 52:1417-32.
Drossaert CH, Boer H, Seydel ER. Health education to improve repeat participation in the Dutch breast cancer screening program: evaluation of a leaflet tailored to previous participants. Patient Educ Couns 1996;28:121-31.
Entwistle VA, Watt IS. Disseminating information about healthcare effectiveness: a survey of consumer health information services. Qual Health Care 1998;7:124-9.
Fausto-Neto A. Percepções acerca dos campos da saúde e da comunicação. In: Pitta AMR, organizador. Saúde e comunicação: visibilidades e silêncios. São Paulo/ Rio de Janeiro: HUCITEC/ ABRASCO; 1995. p. 267-94.
Fawdry R. Prescribing the leaflets. BMJ 1994;51:551-3.
Fitzmaurice DA, Adams JL. A systematic review of patient information leaflets for hypertension. J Hum Hypertens 2000;14:259-62.
Foltz AT, Sullivan JM. Limited literacy revisited implications for patient education. Cancer Pract 1999;7:145-50.
Freemantle N, Harvey EL, Wolf F, Grimshaw JM,Grili R, Bero LA. Printed educational materials: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2000;(2):CD000172.
Freire P. Extensão ou comunicação? Rio de Janeiro: Paz e Terra; 1977.
Freire P. Educação como prática de liberdade. 14a ed. Rio de Janeiro: Paz e Terra; 1983.
Freire P. Pedagogia do oprimido. 10a ed. Rio de Janeiro: Paz e Terra; 1988.
Freire P. Pedagogia da autonomia: saberes necessários à prática educativa. Rio de Janeiro: Paz e Terra; 1997.
Garden AL, Merry AF, Holland RL, Petrie KJ. Anaesthesia information what patients want to know. Anaesth Intensive Care 1996;24:594-8.
Garrud P, Wood M, Stainsby L. Impact of risk information in a patient education leaflet. Patient Educ Couns 2001;43:303-6.
Gibbs S, Waters WE, George CF. Prescription information leaflets: a national survey. J R Soc Med 1990;83:292-7.
Glanz K, Rudd J. Readability and content analysis of print cholesterol education materials. Patient Educ Couns 1990;16:109-18.
Graham W, Smith P, Kamal A, Fitzmaurice A, Smith N, Hamilton N. Randomised controlled trial comparing effectiveness of touch screen system with leaflet for providing women with information on prenatal tests. BMJ 2000;320:155-60.
Granitza A. Aufklarungspflicht, Fach- und Gebrauchsinformationen aus der Sicht der pharmazeutischen Industrie (patient education responsibility, specialty and administration information from the viewpoint of the pharmaceutical industry). Z Arztl Fortbild Qualitatssich 1997;91:649-53.
Habermas J. Teoria de la acción comunicativa. Madri: Taurus; 1987. vol.1.
Harvey HD, Fleming P, Cregan K, Latimer E. The health promotion implications of the knowledge and attitude of employees in relation to health and safety leaflets. Int J Environ Health Res 2000;10:315-29.
Horowitz R, Viscoli C, Berkman L. Treatment adherence and risk of death after a myocardial infarction. Lancet 1990;342:1142-5.
Howells RE, Dunn PD, Isasi T, Chenoy R, Calvert E, Jones PW et al. Is the provision of information leaflets before colposcopy beneficial? A prospective randomized study. Br J Obstet Gynaecol 1999;106:28-34.
Humphris GM, Duncalf M, Holt D. The experimental evaluation of an oral cancer information leaflet. Oral Oncol 1999;35:575-82.
Humphris GM, Ireland RS, Field EA. Immediate knowledge increase from an oral cancer information leaflet in patients attending a primary health care facility: a randomized controlled trial. Oral Oncol 2001;37:99-102.
Jackson C, Lindsey S. Reducing anxiety in new dental patients by means of leaflets. Br Dent J 1995;179:163-7.
Jones R, Finlay F, Crouch V, Anderson S. Drug information leaflets: adolescent and professional perspectives. Child Care Health Dev 2000;26:41-8.
Kee F. Patients' prerogatives and perceptions of benefit. BMJ 1996;312:958-60.
Kruse AY, Kjaergard LL, Krogsgaard K, Gluud C, Mortensen EL, Gottschau A et al. A randomized trial assessing the impact of written information on outpatients' knowledge about and attitude toward randomized clinical trials. The INFO trial group. Control Clin Trials 2000;21:223-40.
Kubba H. An evidence-based patient information leaflet about otitis media with effusion. Clin Perform Qual Health Care 2000;8:93-9.
Lamb G, Green S, Heron J. Can a physician warn patients of potential side effects without causing fear of those side effects? Arch Intern Med 1994;154:2753-6.
Lau RK. Genitourinary medicine and the Internet No.4. Genitourin Med 1997;73:73-4.
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: randomized controlled trial. BMJ 1998;316:1948-52.
Little P, Somerville J, Williamson I, Warner G, Moore M, Wiles R et al. Randomised controlled trial of self management leaflets and booklets for minor illness provided by post. BMJ 2001;322:1214-6.
Luck A, Pearson S, Maddern G, Hewett P. Effects of video information on precolonoscopy anxiety and knowledge: a randomised trial. Lancet 1999;354:2032-5.
Macfarlane JT, Holmes WF, Macfarlane RM. Reducing reconsultations for acute lower respiratory tract illness with an information leaflet: a randomized controlled study of patients in primary care. Br J Gen Pract 1997;47:719-22.
Maggs, FM, Jubb RW, Kemm JR. Single-blind randomized controlled trial of an educational booklet for patients with chronic arthritis. Br J Rheumatol 1996;35:775-7.
Mant J, Carter J, Wade DT, Winner S. The impact of an information pack on patients with stroke and their carers: a randomized controlled trial. Clin Rehabil 1998;12:465-76.
Mazur DJ, Hickam DH. The effect of physicians explanations on patients' treatment preferences: five year survive data. Med Decis Making 1994;14:255-8.
Meredith P, Emberton M, Wood C, Smith J. Comparison of patients' needs for information on prostate surgery with printed materials provided by surgeons. Qual Health Care 1995;4:18-23.
Mintzberg H. Criando organizações eficazes: estruturas em cinco configurações. São Paulo: Atlas; 1995.
Mintzberg H, Ahlstrand B, Lampel J. Strategy safari: a guided tour through the wilds of strategic management. New York: The Free Press; 1998.
Mottram DR, Reed C. Comparative evaluation of patient information leaflets by pharmacists, doctors and the general public. J Clin Pharmacol Ther 1997;22:127-34.
Mumford ME. A descriptive study of the readability of patient information leaflets designed by nurses. J Adv Nurs 1997;26:985-91.
Murphy B, Schofield H, Herman H. Information for family careres: does it help? Aust J Public Health 1995;19:192-7.
Murphy S, Smith C. Crutches, confetti or useful tools? Professionals' views on and use of health educational leaflets. Health Educ Res 1993;8:205-15.
Murray J, Cuckle H, Sehmi I, Wilson C, Ellis A. Quality of written information used in Down syndrome screening. Prenat Diagn 2001;21:138-42.
Nelson D, Coleman K, Walver J. Why are you waiting? Formulating an information pamphlet for use in an accident and emergency department. Accid Emerg Nurs 1997;51:39-41.
Newton JT. The readability and utility of general dental practice patient information leaflets: an evaluation. Br Dent J 1995;178:329-32.
Newton LH, Hall SM. A survey of heath education material for the primary prevention of congenital toxoplasmosis. Commun Dis Rep CDR Rev 1995;5:R21-7.
Paul CL, Redman S, Sanson-Fisher RW. Print material as a public health education tool. Aust N Z J Public Health 1998;22:146-8.
Petterson T, Dornan TL, Albert T, Lee P. Are information leaflets given to elderly people with diabetes easy to read? Diabet Med 1994;11:111-3.
Peveler R, George C, Kinmonth AL, Campbell M, Thompson C. Effect of antidepressant drug counselling and information leaflets on adherence to drug treatment in primary care: randomized controlled trial. BMJ 1999;319:612-5.
Pratt L, Seligman A, Reader G. Physicians view on the level of medical information among patients. Am J Public Health 1957;47:1277-83.
Richard MA, Martin S, Gouvernet J, Folchetti G, Bonerandi JJ, Grobb JJ. Humour and alarmism in melanoma prevention: a randomized controlled study of three types of information leaflet. Br J Dermatol 1999;140:909-14.
Robertson A, Minkler M. New health promotion movements: a critical examination. Health Educ Q 1994;21:285-312.
Rozemberg B. Representação social de eventos somáticos ligados à esquistossomose. Cad Saúde Pública 1994;10:30-46.
Rozemberg B. Saneamento rural em areas endêmicas de esquistossomose: experiência e aprendizagem. Ciência Saúde Coletiva 1998;3:125-41.
Rozemberg B, Silva APP da, Vasconcellos-Silva PR. Impressos hospitalares e a dinâmica de construção de seus sentidos: o ponto de vista dos profissionais de saúde. Cad Saúde Pública 2002;18:1685-94.
Schreiber HL. Aufklarungspflicht, Fach- und Gebrauchsinformationen aus juristischer Sicht. Z Arztl Fortbild Qualitatssich 1997;91:653-7.
Schulman BA. Active patient orientation and outcomes in hypertensive treatment. Application of a socio-organisational perspective. Med Care 1979;17:267-80.
Seals TD, Keith MR. Influence of patient information leaflets on anticonvulsant drug compliance in prison. Am J Health Syst Pharm 1997;54:2585-7.
Simpson W, Johnstone F, Boyd F, Goldberg D, Hart G, Gormley S et al. A randomized controlled trial of different approaches to universal antenatal HIV testing: uptake and acceptability. Annex: antenatal HIV testing assessment of a routine voluntary approach. Health Technol Assess 1999;3:1-112.
Stewart M. Effective physician-patient communication and health outcomes: a review. CMAJ 1995;152:1423-33.
Street E, Drew PJ, Carleton PJ, Carleton PJ, Fox JN, Duthie GS et al. Interactive multimedia information program for use by breast-care nurses a patient acceptability study. Eur J Surg Oncol 1998;35:264-6.
Sumner WN. A evaluation of readable preventive health messages. Fam Med 1991;23:463-6.
Tourigny J. Les effects d'une intervention educative preoperatoire sur la conduite de parents d'enfants de trois a six ans operes dans le cadre d'une chirurgie d'un jour. Can J Nurs Res 1998;30:135-59.
van Es SM, le Coq EM, Brouwer AI, Mesters I, Nagelkerke AF, Collant VT. Adherence-related behavior in adolescents with asthma: results from focus group interviews. J Asthma 1998;35:637-46.
Ward B, Shah S, Eaden JA, Mayberry JF. Patients with inflammatory bowel disease: their response to information leaflets about medical therapy in particular azathioprine. Arq Gastroenterol 1998;35:264-6.
Wilson FL. Patient educational materials nurses use in community health. West J Nurs Res 1996;18:195-205.
Wise PH, Pietroni RG, Bhatt VB, Bond CS, Hirst S, Hooker RJ. Development and evaluation of a novel patient information system. J R Soc Med 1996;89:557-60.
Zakrzewska JM, Leeson RM, Mcluskey M, Vickers M. The development of patient information leaflets. Care of the mouth after radiotherapy. Gerodontol 1997;14:48-53.
Paulo Roberto Vasconcellos-Silva
Rua Pereira da Silva, 444/ 410 Laranjeiras
22221-140 Rio de Janeiro, RJ, Brazil
Received on 22/7/2002.
Reviewed on 27/3/2003.
Approved on 7/4/2003.