PEDIATRICS Vol. 101 No. 6 June 1998, p. e10

ELECTRONIC ARTICLE:
Brief Approaches to Educating Patients and Parents in Primary Care

Frances Page Glascoe^*, Frank Oberklaid, Paul H. Dworkin^§, and Franklin Trimm

From the ^* Department of Pediatrics, Vanderbilt University, Nashville, Tennessee;  Department of Community Child Health and Ambulatory Paediatrics, University of Melbourne, Melbourne, Australia; ^§ Department of Pediatrics, University of Connecticut, Storrs, Connecticut; and  Department of Pediatrics, University of South Alabama, Mobile, Alabama.

	ABSTRACT

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Purpose.  Pediatricians are encouraged by the American Academy of Pediatrics and Bright Futures guidelines to use well-child care as an opportunity to promote learning and development, encourage positive parenting practices, help children acquire behavioral self-control, and enhance the well-being of children and their families. Such counseling can consume considerable provider time. In an era of dwindling resources for health care, there is pressure to deliver services as efficiently and effectively as possible. Thus, the purpose of this article is to view methods for patient and parent education that are not only effective but also brief.

Design.  Review of 114 articles on issues relevant to patient education.

Results and Conclusions.  Parents appear to respond best to information that focuses on their specific area of concern. Media, such as advertising campaigns or office posters, can be helpful for broadening parents' range of interests. In response, verbal suggestions are effective for conveying brief, concrete information when parents are not stressed. Written information should be added for addressing more complex issues. Modeling and role-playing appear especially useful when confronted with problematic parenting or child behavior. These approaches, if selected wisely and applied well, offer families needed assistance that has proven effectiveness in improving children's and families' health and well-being.

	INTRODUCTION

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Approximately 30% of parents worry about their children, even though they are developing and behaving within the broad range of normal.¹ This phenomenon offers a teachable moment for guidance from health care professionals in which parents may welcome the opportunity and benefit from its content.^2-5 Because some concerned parents have children who are at risk for disabilities and school dysfunction,¹ counseling is an important component of promoting optimal development.⁶ Such counseling also is one of the central reasons for health supervision visits. Indeed, various committees of the American Academy of Pediatrics (AAP)^7-9 and the Bright Futures guidelines¹⁰ encourage providers to use well-child care as an opportunity to promote learning and development, encourage positive parenting practices, help children acquire behavioral self-control, and enhance the well-being of children and their families.

These exhortations give rise to two major questions. First, what are the best and most effective ways to counsel families? Second, how can this be accomplished within the time constraints of busy clinics? Although visit length appears to be increasing in recent years (from 10.3 minutes in a 1983 study to 20.4 ± 6.7 minutes in a 1997 study), as does the time devoted to anticipatory guidance (an average of 2.4 minutes [12.4% of visit time]), compared with 0.9 minutes (8.4% of visit time),^11-14 overall, the time spent on well-child care in general and on counseling in particular is still quite modest. This suggests that pediatricians need information on efficient approaches to patient education that are minimally time-consuming.

Accordingly, the goal of this article is to review research on brief and effective methods in patient education and counseling. Described here are several different methods by which health care professionals can counsel and educate parents while minimizing the time required (and the ennui that inevitably ensues from repeatedly giving advice on the same topics). These methods include verbal suggestions, videotapes, information handouts, hand-held health records, role-playing, and modeling. Each approach is described below, along with information about efficacy and optimal application. To identify the various methods, we reviewed 114 studies via searches through the 1980 to 1997 Medline and Psychinfo databases. We paid particular attention to research using randomized control group designs on pediatric populations. Search terms included "patient education," "parent training," "information handouts," "video," "recall," "literacy," "role-playing," and "group well visits."

	VERBAL SUGGESTIONS

Clear, spoken advice is a powerful agent for helping parents acquire new knowledge. However, specific rather than general advice appears better for helping families to learn and apply new information.^15,16 For example, concrete suggestions on behavior management (offered by telephone to 27 mothers of infants between 1 and 5 months of age) were found to be more effective than supportive counseling (offered to 21 mothers matched on infant age, fuss/cry levels, and socioeconomic characteristics) or no counseling (n = 44 matched mothers) in decreasing excessive infant crying.¹⁶ Other studies showed that specific verbal suggestions in combination with supportive counseling (ie, meaning opportunities for parents to share other issues, such as concerns about emotional well-being, and to receive encouragement and validation) can lead to even greater acquisition of knowledge and skills. Brief informative talks increased parents' knowledge (of epilepsy), but a combination of informative talks and supportive counseling was more effective in improving knowledge and also in decreasing parental anxiety.¹⁷

One of the biggest drawbacks to providing education solely via verbal instructions is that parents often have difficulty remembering and understanding what was said.^18,19 One reason is that parents do not always understand the vocabulary used in pediatric encounters.²⁰ The sheer limits of human memory also contribute. Simon showed that 10% of parents had difficulty remembering the diagnosis given at a sick visit, whereas 23% had difficulty recalling dosing instructions of medications.²¹ Recall for numbers appears especially poor.²² Often such difficulties appear related to stress, a known deterrent to remembering. Many parents arrive at a pediatric encounter worried about their child, their parenting abilities, and many other life stressors. In one study, parents were divided into two groups: those with high versus low levels of anxiety.²³ Highly anxious parents had far more difficulty recalling information about their child's condition immediately after a pediatric office visit. Worries about children's behavior, finances, day care, relationships, employment, and past and future events all were deterrents to learning. Furthermore, parents' perceptions that their child's illness was serious and their understanding of the diagnosis strongly affected their willingness to comply with treatment recommendations and keep follow-up appointments. Parents' ability to comply is undermined further by other stressors that serve as serious barriers to compliance, including difficulty with transportation, presence of siblings younger than 36 months of age, language differences, and lack of babysitting services.²⁴

To address anxiety-induced barriers to learning, researchers recommended that pediatricians explore parents' understanding of their child's condition, their worries about the visit, and any behavioral and developmental concerns, and refer families as needed for supportive services (eg, advocacy, social work, psychological counseling, etc). One simple and effective technique for enhancing parental recall (to fill prescriptions and follow discharge instructions) is a telephone call after the initial consultation.²⁵ This facilitated compliance in 90% of the experimental group in contrast to 55% compliance in the control group. Reminder letters and wallet-size cards with names and telephone numbers of physicians also improve the likelihood of complying with recommendations.²⁶

Standardized verbal instructions also have been found to circumvent recall problems. These carefully prewritten statements, usually prepared in clear, understandable language, are designed to address all important aspects of diagnosis and treatment and usually are read or paraphrased to parents. Standardized instructions are known to improve the clarity and scope of information provided, and they also improve recall of discharge instructions, medication, dosing, signs of improvement, and worrisome symptoms (in parents of 197 children receiving emergency room care for otitis media).²⁷ However, it should be pointed out that in all recall studies, the content was specific and relatively simple and did not assess patients' ability to remember and apply complicated sequences of new skills (such as might be involved in behavioral interventions for toilet training, reducing inappropriate behaviors, teaching children positive behaviors, etc) Thus, for more in-depth patient education, oral instruction alone is not likely to be as effective as other methods for delivering information.

	VIDEOTAPES

One approach to educating parents about complicated topics is to use videotapes. Pediatric waiting-room instructional videotapes have been shown to be highly effective in improving parents' knowledge of various child health issues.^28,29 For example, abusive parents who watched a series of videotapes about nonabusive solutions to common parent-child conflicts showed significant gains in knowledge of alternatives to physical punishment, understanding of normal child development, and insight into children's misbehavior.³⁰

The setting and speakers used in videotapes appear to be particularly important, at least for some groups of parents. Mothers who watched a short culturally sensitive videotape (meaning that the speakers were other African-American, low-income, adolescent mothers) of best practices in infant developmental stimulation and feeding were far more likely than were control group mothers (those instructed verbally by white professionals) to communicate with their infant during feeding.³¹ Other studies also support the effectiveness of videotapes when they are culturally sensitive.^32,33

	INFORMATION HANDOUTS

Information handouts are less expensive and generally more available than videotapes.³⁴ One study compared videotaped counseling to information handouts. Both were found to be equally effective in improving parents' disease-specific knowledge (of cystic fibrosis in a study of parents seeking well-child care in a university hospital).³⁵ Information handouts have been demonstrated to be effective in improving outcomes such as compliance, satisfaction with care, and parent knowledge. For example, in a study of 11 000 patients given information handouts on tetanus vaccines and then followed for 7 months, vaccination rates increased threefold.³⁶ Handouts also increased compliance with treatment recommendations.^37,38 Providing parents written information on fevers and urinary tract infections decreased by half the number of inappropriate telephone calls and reduced by one half to three fourths unnecessary office visits.^39,40 In a comparison of oral versus written information, parents receiving written information were better able to follow through with medical instructions.^27,41

Because parents are adult learners, patient education studies conducted in general practice settings also shed light on the impact of written information. One such study found that adult patients usually appreciate written information and appear more satisfied with care when such information is made available.⁴² A study of >4000 patients in Great Britain showed that 97% read information handouts and 70% retained them for more than 12 months. Furthermore, those given handouts 1) were more satisfied and acquired more knowledge (of medication side effects); 2) were not more likely to report spurious side effects; and 3) had greater knowledge of the medications' purpose and dosing (although they were not better able to recall the name of the medication).^43,44 Another study showed that informational leaflets significantly decreased anxiety, facilitated patient-staff interactions, and increased satisfaction with patient care better than verbal instruction alone.⁴⁵

Although it has been demonstrated clearly that information handouts can be effective educational tools, an important issue is the best way of sharing them with parents. Should handouts be left in waiting rooms, given to parents without additional instruction, or carefully discussed during the office visit? Research clearly supports the latter approach. One study showed that in the United Kingdom, adult patients rarely read or took home information handouts left in waiting areas, although they were found to read and recall short messages on waiting room bulletin boards.⁴⁶ In a related study, information handouts sent through the mail in conjunction with a media campaign (to reduce risk for malignant melanoma) were more effective than were informational handouts mailed alone.⁴⁷ This suggests that patient awareness of and interest in a particular topic is essential for handouts to be effective teaching tools, emphasizing the concept of a teachable moment.

A personalized approach to disseminating information handouts appears most effective. In one study, patients learned, recalled, and understood considerably more information about options in cancer treatment when they had follow-up contact with an oncology nurse along with written literature.⁴⁸ In another, computerized instruction that allowed patients to learn at their own pace, lead to improved health status and communication with health care professionals.⁴⁹ A study of efforts to discourage smoking in 2901 mothers of newborns compared the effectiveness of information packets together with oral instruction from a pediatrician to written information without oral instruction. The combined method produced higher quit rates and lower relapse rates.^50,51 Similarly, parents who received counseling from their child's pediatrician along with written information and test results were more likely to smoke outside their homes than were parents who received counseling only.⁵²

One noteworthy approach to personalizing handouts is The Injury Prevention Program (TIPP) from the AAP. This package includes a parent survey designed to highlight areas of informational needs. Once needs are identified, specific TIPP information handouts and other materials can be selected. Perhaps because individualization is an inherent part of the TIPP, the majority of studies conducted have shown substantial success in improving parents' knowledge and implementation of safety measures.^53-55

Information handouts seem especially helpful when the topic is complicated and involves teaching skills that have multiple steps. One study showed that written leaflets given to parents on a waiting list for individual counseling services were as effective as individual counseling for eliminating sleep problems.⁵⁶ In another study, a 10-page handout on behavior modification skills decreased oppositional behavior in children with attention deficit hyperactivity disorder and reduced parents' need for multiple training sessions.⁵⁷

Information handouts also appear useful in building parenting skills longitudinally. In one study, handouts were sent periodically at specific ages to parents after the birth of their child.⁵⁸ The newsletters addressed those parental concerns most common to children according to their age and emphasized knowledge about development, parenting, health care, and emotional well-being. More than 800 parents were recruited for satisfaction and knowledge surveys, and >70% reported improvements in knowledge about development, parent-child relationships, and parental self-confidence. Similarly, activity sheetsage-paced according to the US well-visit schedule and designed to help parents promote their child's developmental progress in language, motor, and self-help/socializationwere rated highly by parents, many of whom reported that the activity sheets increased their knowledge of development and their willingness to discuss developmental issues with their primary care provider.⁵⁹

Several conclusions can be drawn from the above: 1) parents and patients appear to take in written information best when the topic is of interest and concern; 2) written information is a more effective teaching tool if accompanied by a personalized oral message from a health care professional; and 3) information handouts can be used to teach complicated sequences of skills.

	PARENT-HELD RECORDS

Parent-held records are widely used in Europe and Australia and are becoming increasingly popular in the United States. Such records are used to note immunizations, provide schedules of visits for health surveillance, and inform parents on a range of issues such as nutrition, child development, physical growth, and behavior. High levels of parent and provider satisfaction are associated with the use of health records.^60-62 Although most parents retain and use their records, this varies substantially according to whether parents received clear instructions to bring their child's record to each visit. Far more parents maintained and used records when instructed either orally or in writing.^63,64

Despite the popularity of parent-held records and their ability to provide anticipatory information on a range of developmental and behavioral topics, the efficacy of these in preventing or intervening with developmental and behavioral difficulties has not been studied. Some caveats can be drawn from a study demonstrating differences in how parents/patients versus providers perceived health records. Parents/patients tended to view them as a personal document for their own reference, whereas physicians tended to view records as a communication and management tool.⁶² In any case, it is probably safe to view parent-held records as we would any other form of written information and assume that it is best to highlight critical points via individualized verbal instruction and supportive counseling.

	QUESTIONS OF LITERACY, LANGUAGE DIFFERENCES, AND OTHER BARRIERS TO PATIENT EDUCATION

The widespread use and effectiveness of written information in patient education raises questions about literacy, language barriers, and readability. In the United States, ~20% of the adult population is considered functionally illiterate (defined as reading below the 8th-grade levelthe difficulty level of most newspapers and digest-type magazines). In one study of low-income elderly adults, mean reading skills were found to approximate the 5th-grade level, equivalent to skills of the average 10-year-old child.⁶⁵ Another study found that younger adults read somewhat better, at an average grade level of 8.7 (13- to 14-year-old range), but still about five grade levels below their highest complete school grade (for which the mean was 12.1 grades (17- to 18-year-old range).⁶⁶ In Louisiana, one of the more impoverished states in the United States, younger adults had average reading levels closer to the high 5th-grade level, whereas adults older than 60 years of age read at the high 2nd-grade level.⁶⁷ An Australian study showed average reading performance clustered at the 8th-grade level and that two thirds of all information pamphlets were written above the 8th-grade level.⁶⁸ A US study showed that only 25% of materials produced by the AAP were written for readers at a less than 9th-grade level.⁶⁹ In another study, 15% of patients could not read and interpret a prescription bottle, and 37% could not comprehend dosing instructions.⁷⁰

Foreign-language barriers affect ~10% of US citizens and substantial numbers of families in the United Kingdom and Australia. Often there is considerable overlap between those who do not speak English and those with limited literacy. Even so, neither language barriers nor illiteracy precludes an interest in information. In one study, non-English speakers expressed frustration with the lack of information written in their primary language.⁷¹ Another study showed that almost all patients, whether or not they could speak English or read, clearly wanted more information about a range of topics.⁷² Thus, the challenge is to determine ways to effectively and efficiently provide patients of all backgrounds with the information they need.

Several studies suggest that one approach to circumventing illiteracy and foreign-language barriers and improving comprehension is to ensure that information handouts are written at or below the 8th-grade level (average 13-year-old reading level) and preferably closer to the 5th-grade level (average 10-year-old reading level). Improving readability typically is accomplished by reducing sentence length and vocabulary, eliminating multiple prepositional phrases, avoiding passive verb tenses, and checking the results with the standard readability formulas found in most word-processing programs.⁷³ An advantage of improving readability is that even literate parents prefer easy-to-read material (eg, when given a choice between vaccine information written at the 3rd- to 4th-grade level vs more sophisticated literature).⁷⁴ A second approach is to deliver information handouts along with oral guidance. The many studies showing that this combination is more effective than use of information handouts alone suggest a primary mechanism by which illiteracy is circumvented. A perhaps optimistic aside is that many nonreaders or poor readers, much like those who do not speak the primary language of the country in which they live, often know someone who can help them understand written material. A final approach is to have written material translated into other languages for parents who do not speak English.

	OTHER TEACHING TECHNIQUES

Modeling appropriate behavior, coaching, and role-playing are hands-on teaching techniques that emulate the "see one, do one, teach one" adage of precepting in medical school and residency training. Many patient educators consider these techniques a form of problem-solving and contend that curricula with this type of orientation lead to improved ability to apply new knowledge, compared with less "hands-on" forms of instruction. Modeling has been shown to improve the ability of residents and medical students to communicate more effectively, develop better interpersonal skills with patients, and intervene when there are signs of drug abuse in patients and parents.^75-79 Role-playing and other simulation activities are shown to reduce aggressive behavior, improve social skills, and increase communication skills in adolescents, and to improve children's knowledge about traffic safety.^80-82 Role-playing was found to be superior to written information in improving parents' ability to identify and report children's illness.⁸³ Both modeling and role-playing were effective in teaching a broad range of parenting skills.⁸⁴ Similarly, direct coaching has been shown to help children and parents reduce pain (eg, use a party blower as a distraction technique) or learn such procedures as self-catheterization.^85-87

It may appear that role-playing, modeling, and coaching are relatively time-consuming. However, several studies have involved simple and brief interventions with remarkable success. One study looked at the effects of modeling by having a group of parents observe professionals administering rating scales of development and behavior to children. A second group of parents completed the scales on their own as a parent report tool. A control group did neither. There were no differences between the group who completed rating scales on their own and the group who observed professionals. Both were far more interactive with their infants, and their children had better fine motor skills (1 to 4 months later) than did control group families.⁸⁸ The researchers concluded that questionnaire completion offers parents a chance to learn about and eventually imitate appropriate behaviors.

The simplicity of these interventions, coupled with the impact that physicians' suggestions have on patients and families, implies that simply pointing out high-risk parenting behaviors and providing appropriate models and opportunities for practice should be highly effective in improving parenting skills.⁸⁹ Furthermore, coaching and modeling can readily capitalize on "teachable moments" such as immediately after observing a parent interact with his or her child in a less than desirable manner. Appropriate topics would logically address those behaviors that are visible and demonstrable (eg, showing parents how to promote language development when a child gives an object to his or her mother, demonstrating a better disciplinary technique after a parent is observed punishing a child too harshly, demonstrating how to read to children, etc.). Children themselves can be coached not only in how to tolerate office procedures but also about behavior and development (eg, by asking them to practice obeying their parents, modeling if needed, and then demonstrating for the parent appropriate social reinforcement).

One of the few studies to examine the effectiveness of modeling focused on promoting children's literacy through parental involvement⁹⁰a topic of much interest to health care professionals because of the significant relationship between illiteracy and unhealthy behaviors (eg, illiterate parents are more likely to smoke, lack insurance, be overweight, and not breastfeed).^66,91 Accordingly, researchers compared three different approaches: placing volunteers in pediatric waiting rooms who read aloud to patients, having the pediatrician counsel parents about literacy development, and/or providing books for children at each visit.⁹¹ Of the three approaches, parents who received books were four times more likely than were other parents to report having read to their child in the last 24 hours or to mention that one of their child's favorite activities was being read to. Indeed, the authors contend that the primary barrier to literacy-promoting experiences is the absence of books in the home. As an aside, this is exciting because it is one of the easiest barriers to removea point demonstrated neatly in this study because the authors solicited book donations from toy companies and other sources. More to the point, it seems unfair to tarnish the reputation of modeling as an effective teaching technique on the basis of this study: how could parents be expected to imitate the example of volunteer readers if they had no books at home? One surely overstated conclusion is that if the behavior we want parents and patients to model requires tools, the tools should be made available.

	GROUP WELL VISITS

Some pediatric practices identify small cohorts of families who have children of the same age (eg, 8- to 10-year-olds) and conduct group well visits, usually lasting 1 hour, that cover anticipatory guidance, safety and prevention issues, psychosocial concerns, etc. Physical examinations and vaccinations are provided separately. In a study comparing families randomized to group or traditional well visits, Osborn and Wooley⁹² found that mothers attending group visits were more likely to attend subsequent well visits and were less likely to seek advice between visits. Although the amount of time physicians spent on group versus traditional well care was identical across conditions, parents participating in group visits received 1 hour of physician time, whereas those in the traditional care received an average of 16 minutes.

The content of visits in group well care focused less on physical aspects of care and more on parenting issues. During group visits, parents were more likely to raise recommended topics from Guidelines for Health Supervision⁹ and other topics of concern than they were at individual visits.⁹³ Given that only 30% of families have physical concerns at well visits and instead have numerous psychosocial concerns,⁹⁴ the greater ability of group well visits to address parents' most pressing issues is an exciting finding. Furthermore, research illustrating the close association between certain parental concerns and childhood problems suggests that enhancing parents' opportunities to discuss their concerns is advisable.^1,95 Recent research on group well visits showed that children whose parents attended these were as likely as those receiving individual care to be vaccinated and somewhat less likely to use the emergency room between visits.¹³ Finally, >95% of parents preferred group to individual well visits.⁹²

	CONCLUSIONS

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Parents appear to respond best to information that focuses on their specific areas of concern. Media such as advertising campaigns or office posters can be helpful for broadening parents' range of interests. Verbal suggestions can be used alone for conveying brief, concrete information, particularly when parents are not stresseda condition that deters recall. Written information should be added for addressing more complex issues. Modeling and role-playing appear especially useful when confronted with problematic parenting or child behavior. In selecting among patient education methods, it is helpful to recognize that various outcomes can be expected from each approach. Selection among methods should be made and tailored according to the needs and characteristics of parents and the topic at hand. All approaches, if selected wisely and applied well, offer families needed assistance that has proven effectiveness in improving children's and families' health and well-being. Table 1 shows sources for readily available patient education materials.

Limitations in the current review and in the available literature are that few studies examine both the efficacy and the time-efficiency of the approaches used. Accordingly, we used our clinical and research experience to decide which approaches appeared to take little time to either arrange or implement. As a consequence, we did not discuss such approaches as practice-sponsored parent training classes,^96-99 training parents to train other parents,^100,101 and deployment of other health personnel to conduct home visits such as nursing staff,^102,103 medical students,¹⁰⁴ or specially trained home visitors.^99,105-110

Additional research is needed on the use of patient education techniques in conjunction with assessment tools that assist with selection among methods and content.^111,112 Also worthy of evaluation is the extent to which incorporating a family-focused, family systems approach enables the practitioner to better assess family structure and function and establish a more effective therapeutic alliance with parents.¹¹³ Studies are also needed to assess the extent to which acknowledging and incorporating cultural beliefs and practices when working with ethnic minority families enhances satisfaction with care and the acceptance of traditional preventive interventions.¹¹⁴

	FOOTNOTES

Received for publication Nov 4, 1997; accepted Jan 16, 1998.

Reprint requests to (F.P.G.) Department of Pediatrics, Vanderbilt University, 426 Medical Center S, Nashville, TN 37232-3573.

	ABBREVIATIONS

AAP, American Academy of Pediatrics. TIPP, The Injury Prevention Program.

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