Linguistic Validation of Interactive Educational Interventions in Neurologic Trauma

doi:10.1016/j.wneu.2017.07.118

World Neurosurgery

Volume 107, November 2017, Pages 87-93

Portions of this work were presented at the 2017 American Association of Neurological Surgeons Annual Scientific Meeting, April 2017, in Los Angeles, California.

https://doi.org/10.1016/j.wneu.2017.07.118 Get rights and content

Background

Neurological surgeons oftentimes educate patients and their families on complex medical conditions and treatment options. Time constraints and varied linguistic and cultural backgrounds limit the amount of information that can be disbursed. In this study, we assessed the linguistic validity of interactive educational interventions in non-English-speaking patients with traumatic brain injury (TBI) and concussion and their families.

Methods

A total of 273 English-, Spanish-, Korean-, and Vietnamese-speaking neurotrauma patients (n =124) and family members (n =149) completed a presurvey to evaluate their incipient understanding, interacted with an iPad-based iBook (Apple) on concussion or TBI in their native language, completed a postsurvey to gauge changes in understanding, and then consulted with their neurosurgeon.

Results

All participants (124 patients and 149 family members) had significantly increased (95% confidence interval [CI], P < 0.01) postsurvey scores (average pre-iBook score, 2.810; average post-iBook score, 4.109), regardless of native language or cultural background. Caucasian participants scored significantly higher than the combination of all ethnicities on both the baseline survey (95% CI, P < 0.01) and the post-iBook survey (95% CI, P < 0.01), and Asian participants scored significantly lower (95% CI, P < 0.05) than the combination regardless of similar baseline scores.

Conclusions

Interactive iBook-based interventions on concussion and TBI can increase participants' comprehension, improve their comfort with their medical condition and the follow-up care, and enhance communication with their physicians. These findings are linguistically valid irrespective of the participants' native language or cultural background.

Introduction

Traumatic brain injury (TBI) is a prevalent societal problem, affecting 2.5 million individuals each year, at an annual cost of $60 billion in medical expenses and productivity losses in the United States alone.1, 2, 3, 4, 5 A variety of contributing etiologic factors can lead to TBI, and patients can present with a wide array of neurologic deficits necessitating careful examination, diagnosis, and intervention.6, 7, 8, 9, 10 Even minor head injuries, such as concussion (typically defined as a Glasgow Coma Scale score of 13–15), can lead to numerous psychophysiological defects that present immediately or at some time after the insult. Repeated concussions have been linked to severe neurodegenerative disorders, particularly chronic traumatic encephalopathy.11, 12, 13, 14

Neurological surgeons are challenged with the important responsibility of treating patients with TBI. Along with surgical and medical interventions, this entails educating patients and their families on the spectrum of TBI, any surgical interventions performed, the recovery process, and preventative measures to reduce further damage.15, 16, 17, 18 The implementation of pedagogic interventions, such as promotion of helmets and protective equipment for children and simple tips to prevent falls in elderly patients, may help prevent further injury and repeat TBI or concussion.16, 17, 18

Interactive, easy-to-read educational materials that engage patients and their family members can facilitate active learning, knowledge acquisition, and long-term information retention in a variety of clinical and nonclinical locations.19, 20, 21 Furthermore, comparisons with text-based educational material have demonstrated the advantages of active electronic educational interventions in both preoperative and postoperative settings, specifically in the field of neurotrauma.22, 23, 24, 25, 26, 27, 28

A variety of factors, including inadequate information, lack of time, linguistic barriers, and varied cultural backgrounds of patients, can limit the amount of knowledge that can be disbursed by the physician and lead to suboptimal patient education through any medium.29, 30 Although the efficacy of interactive educational interventions, such as educational iBook modules presented on an iPad (Apple, Cupertino, California, USA), has been demonstrated in English-speaking patients of all ages who are familiar with such technology, the linguistic validity of this intervention has not yet been investigated. In the present study, we assessed and compared the linguistic validity of interactive educational interventions in non-English speaking patients with TBI or concussion and their families as opposed to native English speakers (Figure 1). We hypothesized that interactive presentation of information in outpatient settings will improve self-reported patient knowledge and help optimize the patient–physician interaction.

Section snippets

Methods

English-, Spanish-, Korean-, and Vietnamese-speaking patients and accompanying family members attending the American College of Surgeons–verified level I trauma center at University of California Irvine between August 2015 and June 2017 consented to participate in this Institutional Review Board–approved study. After providing consent, the participants received a presurvey to evaluate their incipient understanding of their medical condition, treatment options, and follow-up care. Survey

Results

Of the 273 patient and family member participants, 156 (57%) viewed the iBook in English, 70 (26%) viewed it in Spanish, 26 (9%) viewed it in Vietnamese, and 21 (8%) viewed it in Korean. Cronbach's α was calculated using the validation questions included in the extended surveys (α > 0.750). Paired t test analyses of presurvey and postsurvey responses at a 95% confidence interval (CI) were tabulated.

All participants, regardless of native language, had significantly improved postsurvey scores (P

Interpreted Results and Past Experience

As evidenced, after reading the interactive educational iBooks, all participants showed significant improvements in self-reported knowledge and perceived understanding of their disease regardless of native vernacular or ethnicity. The presurveys and postsurveys administered in this study were synthesized using statistical software, and a random set (n = 121) consisted of multiple-question clusters, allowing for analysis of internal consistency, validity, and reliability of participant responses

Conclusion

The interactive iBook-based interventions on concussion and TBI were associated with improved participant comprehension, increased patient comfort with their medical condition and related follow-up care, and enhanced communication with their physicians. These findings are linguistically valid irrespective of participants' native language or cultural background, and can help overcome educational hurdles faced by physicians.

Acknowledgments

We thank Julie Youm, PhD, Warren Wiechmann, MD, Amir Mahmoodi, BS, Melissa Huang, BS, and David Bustillo, BA from the University of California Irvine School of Medicine for their help in creating and distributing the iBooks on the Apple iBook Store. We also thank Sherrie H. Kaplan, PhD, from the University of California Irvine Health Policy Research Institute for her expertise in creating the surveys used in this study.

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Health Literacy in Neurosurgery: A Scoping Review
2022, World Neurosurgery
Citation Excerpt :
Participants preferred eBooks to pamphlets.72,73 However, older age and ethnicity were associated with lower increases in knowledge.72,74 Seven studies examined three-dimensional physical models.62,63,65,69,70,75
Low health literacy is prevalent and associated with suboptimal health outcomes. In neurosurgery, social determinants of health are increasingly recognized as factors underpinning outcomes, as well as access to and use of care. We conducted a scoping review to delineate the scope of existing literature regarding health literacy in the field and facilitate future research.
A scoping review was conducted using the PubMed, Embase, and Scopus databases. Titles and abstracts were screened for relevance. Studies meeting prespecified inclusion criteria underwent full text review. Relevant data were extracted.
Of 5056 resultant articles, 57 manuscripts were included. Thirty-seven studies (64.9%) investigated personal health literacy, while the remaining 20 (35.1%) investigated organizational health literacy. Domains of health literacy investigated were science (36, 63.2%), fundamental (20, 35.1%), and civic (1, 1.7%). No studies investigated numeracy. Recall among patients after discussions with neurosurgeons is low. Patient perspectives are often erroneous. Patient informational needs are often unmet. Written patient educational materials are written at a level too complex for the average patients. Videos are mostly of poor quality. Multimodal audiovisual interventions, eBooks, models, and virtual reality are shown to be effective methods for promoting recall.
Studies examining health literacy in neurosurgery primarily focus on the topic indirectly, most often via written educational materials and recall after educational interventions. Increasing awareness of health literacy among neurosurgeons, assessing health literacy, and incorporating health literacy-informed counseling approaches are warranted to improve patient care.
Patient Education in Neurosurgery: Part 2 of a Systematic Review
2021, World Neurosurgery
Citation Excerpt :
All 5 studies found that patients receiving education via e-books had improved knowledge scores. This improvement occurred regardless of age, native language, or cultural background, although elderly patients and Asian patients had lower knowledge scores than did patients in other age-groups or ethnic groups.30,32 Two studies30,31 determined that e-books were preferred to paper pamphlets.
Increasing focus has been placed on patient education to optimize care. In the second part of a 2-part systematic review, we characterize the scope of interventions specifically created to improve neurosurgery patient education, assess the effectiveness of these interventions, and extract features of existing interventions that may be incorporated into future patient education interventions. Our findings may help promote the creation of effective, patient-centered educational interventions.
A 2-part systematic review was conducted using the PubMed, Embase, and Scopus databases. Titles and abstracts were read and selected for full text review. Studies meeting prespecified inclusion criteria were reviewed in full and analyzed for study design, aim, population, interventions, and outcomes.
Of 1617 resultant articles, 33 were included. Print materials, electronic materials, models, and interventions using multiple modalities improved patient knowledge, decreased anxiety, and increased satisfaction. Electronic materials were preferred. Interventions using multiple modalities engaging multiple sensory systems were reported most beneficial. Video was rated the most effective medium for reinforcing spoken conversation between neurosurgeons and patients. Three-dimensional models decreased the time required for preoperative patient conversation but could be perceived as emotionally confronting. Virtual reality was preferred to patient models.
Electronic interventions using multiple modalities in concert with each other may be most effective. Interventions should incorporate baseline knowledge and health literacy and address patient concerns and needs in a manner that is valid cross-contextually, uses clear communication, and is continuous. These interventions will improve the patient-friendliness of discussions with patients.
The Impact of Unmet Communication and Education Needs on Neurosurgical Patient and Caregiver Experiences of Care: A Qualitative Exploratory Analysis
2019, World Neurosurgery
Citation Excerpt :
Approaches include clinician-developed and -approved online videos, websites, and mobile health applications. One recent evaluation of tablet-based interactive education modules used in a neurotrauma clinic found that this modality was superior to traditional written pamphlets with regard to patient-reported knowledge levels and satisfaction.36,37 Alternatives to this are online or computer-based education programs that prepare patients for surgery by explaining anesthesia and what to expect during hospitalization and at discharge.38
To describe neurosurgical patient and caregiver perceptions of provider communication, the impact of patient education, and their understanding of information given to them throughout the neurosurgical care trajectory.
We organized focus groups composed of patients who had been hospitalized on the neurosurgical service at 5 urban academic tertiary referral hospitals within a large university health system, along with the patients' caregivers. During focus groups, we used semistructured questions to answer the study questions. Content analysis was used to analyze the data.
Forty-three patients and caregivers took part in 5 focus groups. In total we identified 12 coding categories (or topics) that were associated with patient and family information needs. Despite the fact all patients were receiving care within the same health system, often with the same care team and clinical environments, their experiences often could not have been more different. We found stark variations in how patients and caregivers described the quality of communication and patient education they received that affected their satisfaction. Satisfied patients and caregivers generally felt well informed and reported good understanding of the clinical care plan throughout the perioperative course, whereas dissatisfied patients struggled with unanswered questions, unmet information needs, and a sense of confusion throughout their care experience.
Our study describes several unmet needs, finds inconsistencies in how information is delivered and a lack of patient-centered and caregiver-centered approaches to communication. Neurosurgery groups should identify unmet needs at their institution and implement strategies and interventions to improve the patient and caregiver experience.

: Conflict of interest statement: R.S. is funded in part by a Medical Scientist Training Program Grant from the National Institutes of Health (T32-GM08620). The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

: Ronald Sahyouni and Amin Mahmoodi contributed equally to this work and should be considered co–first authors.

: Supplementary digital content available online.

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Original ArticleLinguistic Validation of Interactive Educational Interventions in Neurologic Trauma

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Interpreted Results and Past Experience

Conclusion

Acknowledgments

Lancet

Patient Educ Couns

Clin Neurol Neurosurg

Lancet

Am J Otolaryngol

Traumatic brain injury and concussion

Incidence of traumatic brain injury in the United States

J Head Trauma Rehabil

Traumatic brain injury in the United States: an epidemiologic overview

Mt Sinai J Med

Prevalence of traumatic brain injury in the general adult population: a meta-analysis

Neuroepidemiology

Traumatic brain injury in the United States: emergency department visits, hospitalizations and deaths 2002-2006

The epidemiology and impact of traumatic brain injury: a brief overview

J Head Trauma Rehabil

Recurrent concussion and risk of depression in retired professional football players

Med Sci Sports Exerc

Concussion in professional football: summary of the research conducted by the National Football League's Committee on Mild Traumatic Brain Injury

Neurosurg Focus

Injuries in youth football: national emergency department visits during 2001–2005 for young and adolescent players

Acad Emerg Med

Traumatic brain injury and posttraumatic stress disorder: a preliminary investigation of neuropsychological test results in PTSD secondary to motor vehicle accidents

Brain Inj

Investigating baseline neurocognitive performance between male and female athletes with a history of multiple concussion

J Neurol Neurosurg Psychiatry

Cognitive effects of one season of head impacts in a cohort of collegiate contact sport athletes

Neurology

Population-based study on patients with traumatic brain injury suggests increased risk of dementia

J Neurol Neurosurg Psychiatry

The spectrum of disease in chronic traumatic encephalopathy

Brain

Evaluation of a promotional strategy to increase bicycle helmet use by children

Pediatrics

Impact of a theory-based intervention to increase bicycle helmet use in low-income children

Inj Prev

“Help seniors live better, longer: prevent brain injury”: an overview of CDC's education initiative to prevent fall-related TBI among older adults

J Head Trauma Rehabil

Active Learning: Creating Excitement in the Classroom. ASHE-ERIC Higher Education Report no. 1

Cooperative Learning for Higher Education Faculty. American Council on Education Series on Higher Education

Original Article
Linguistic Validation of Interactive Educational Interventions in Neurologic Trauma