Education attainment level of caregivers versus readability level of written instructions in a pediatric emergency department

Our objectives were 1) to determine the education attainment level (EAL) of parents attending the pediatric emergency department (PED); 2) to assess the readability level (RL) of the written instructions available to these parents; and 3) to revise these instruction forms at a level of comprehension based on the EAL of parents. We used a questionnaire survey of EAL and RL assessment using the SMOG and FOG readability formulas. We then revised the written instructions and used parents in the PED to pretest them. The setting was a PED in a tertiary care hospital (Children's Hospital of Western Ontario). The participants were 1034 parents of children in the PED between 8 AM and 11 PM over a six-month period. Parents were chosen at 30-minute intervals on randomly selected weekdays and weekends. A total of 1022 completed the study. Seven forms commonly used in the PED were assessed for RL. Seven forms were rewritten at grade 6 to 7 RL, and each was pretested in 21 to 24 parents or guardians in the PED using a standardized questionnaire with open-ended questions. Ninety percent of respondents spoke English, and 85% had English as their first language. Forty-nine percent of parents had a grade 13 or lower EAL. This included the following EALs: < grade 12EAL, 23%; < grade 10 EAL, 15%; and < grade 8 EAL, 4%. Of the seven forms tested, five were written at a college RL. Pretesting of revised forms elicited the following responses from parents: easy to understand (100%), understood everything (96-100%), worth remembering (77- 96%), liked the form (67-100%), found it informative (52- 85%), and thought it was applicable to all people (82-100%). They most frequently commented that the forms were easy to read and easy to understand. Our study showed that discharge instructions are written at a RL at which approximately 50% of the population served may not understand. This is supported by available data suggesting that forms should be written at a grade 6 or lower RL. Properly designed forms that are written at the grade 6 to 7 level were easy to understand and were associated with parental satisfaction. Design of these forms should not only involve medical personnel but also readability consultants and parents or caregivers.