Evaluation of occupational therapy pre-discharge home visit information leaflets for older adults.
Abstract: Purpose: This study evaluated the use, quality and readability levels of occupational therapists' pre-discharge home visit information leaflets.

Method: One hundred and twelve surveys were sent via email to occupational therapists working with older people. The International Patient Decision Aids Standards and the SMOG Readability Formula were used to analyse five occupational therapy home visit leaflets, supplied by the 11 occupational therapists who responded to the survey.

Results: The five leaflets had low scores in relation to providing unbiased and detailed information. In addition, the reading level of the information leaflets was, on average, four grades higher than the recommended level.

Conclusion: Therapists need to ensure that the information within home visit leaflets is relevant, evidence based, and targeted at the correct readability level.

Key words:

Home visit, information leaflet, communication.
Article Type: Report
Subject: Activities of daily living (Surveys)
Occupational therapists (Surveys)
Pamphlets (Usage)
Evidence-based medicine (Usage)
Occupational therapy (Practice)
Occupational therapy (Evaluation)
Patient satisfaction (Surveys)
Authors: Atwal, Anita
Luke, Alexandra
Plastow, Nicola
Pub Date: 08/01/2011
Publication: Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 College of Occupational Therapists Ltd. ISSN: 0308-0226
Issue: Date: August, 2011 Source Volume: 74 Source Issue: 8
Topic: Event Code: 200 Management dynamics
Product: Product Code: 2731900 Pamphlet Publishing NAICS Code: 511199 All Other Publishers
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 265976937
Full Text: Introduction

Occupational therapy pre-discharge home visits involve taking patients to their home for a short period of time and assessing their ability to perform some occupations of daily living within their own environment (Atwal et al 2008a). Previous research found dissatisfaction with aspects of the occupational therapy pre-discharge home visit in acute care settings. Some older adults found the home visit experience demoralising, daunting and anxiety provoking because of weak communication, poor preparation and their lack of involvement in decision making (Atwal et al 2008b). The home visit process, therefore, depends upon good information exchange between the patient, carer, therapist and other agencies. A Cochrane review recommended the use of both verbal and written health information when communicating with patients (Johnson et al 2003).

Information leaflets are a form of written health information that may enhance the communication between patients and professionals (Clerehan et al 2005). To do this, they need to take into account the specific needs of their recipients (Mountain and Pighills 2003). However, three Australian studies found that occupational therapy leaflets were not designed specifically to meet the needs of older adults (Sharry et al 2002, Griffin et al 2006, McKenna and Scott 2007). Furthermore, information leaflets that discount the specific needs of older adults may not have the desired positive effect on patient outcomes (Paul et al 2003, Marshall and Williams 2006, Freemantle et al 2008). Despite this, a literature search using Medline and Cinahl (1990-2010) found that, within occupational therapy, there were no research studies that explored the quality of information leaflets for older adults in the United Kingdom (UK). A match between written information and the literacy skills of older adults is one aspect of information sheet quality (Sharry et al 2002, Griffin et al 2006, McKenna and Scott 2007). The aims of this research were:

1. To determine what proportion of health care organisations used printed home visit leaflets as part of the occupational therapy home visit process with older adults in acute care

2. To analyse the readability and quality of home visit information leaflets provided by occupational therapists working with older adults in acute care.

The study occurred in two phases and over 3 months, from March 2010 to June 2010.

Phase 1: A survey to investigate the use of home visit information leaflets


An email survey was used to identify the number of UK health organisations providing information for older adults on pre-discharge home visits in acute care. The survey tool was piloted with seven postgraduate occupational therapists. One hundred and seventy-one acute health care trusts were identified via the internet. Twenty-three did not have acute care services for older adults. A further 36 had no contact details available on the internet.

In total, 112 surveys were sent to occupational therapists working in acute care services with older adults. The participants received two email reminders. Participants were asked about the use of a pre-discharge information leaflet within occupational therapy practice, whether it was perceived to be effective, whether the tool had been evaluated, and how it had been formulated. The questions were devised from existing good practice checklists (see Table 1). Occupational therapists were also requested to send the researchers a home visit information leaflet, if one was used.


Eleven occupational therapists responded to the survey. Of these, six provided home visit information leaflets as part of their response; however, only five were suitable for analysis. Due to the inadequate (10%) response rate, it was not possible to determine the proportion of health care organisations that used home visit information leaflets within acute care with older adults. Five therapists who responded to the survey reported that they had never used a leaflet. Four therapists perceived information leaflets as a useful tool that could enhance practice by clarifying the role of the occupational therapist, and provide information about the discharge or the home visit process. Three therapists reported user involvement in information leaflet design, and that they had been designed specifically for older adults. Three therapists reported that the information leaflet had been formally evaluated.

Phase 2: The quality and readability of home visit information leaflets


Five home visit information leaflets were rated by two master's degree occupational therapy students using the International Patient Decision Aids Standards (IPDAS) (Elwyn et al 2006) and the SMOG Readability Formula (Smith et al 1998, White et al 2004).

International Patient Decision Aids Standards (IPDAS): The IPDAS is a 64-item assessment of patient decision aids across three dimensions of content, development process and effectiveness. It was formulated using an online Delphi process, with an international group of collaborators to assess the quality of decision aids (Elwyn et al 2006).

SMOG Readability Formula: This tool, developed by McLaughlin (1969), uses vocabulary difficulty and sentence length to predict the difficulty level of a text (DuBay 2004). Most research investigating the readability of information leaflets has occurred using this tool (Smith et al 1998, White et al 2004).

Review method: Both reviewers were trained by a member of the research team. Disagreement between the two reviewers was moderated by a third reviewer. If there was agreement with one of the reviewers then this score was used. If there was a disagreement between all three reviewers then the three reviewers met to discuss and agree their scores.

Ethical approval was obtained from Brunel University Research Ethics Committee.


There was good agreement between the two reviewers when assessing the five home visit leaflets.

International Patient Decision Aids Standards (IPDAS): The highest score using the IPDAS was 13 out of a maximum score of 41 (Table 2). In assessing the content of the leaflet, only three of the leaflets presented information about the home visit process. One of these leaflets focused on the role of the occupational therapist. Only one leaflet, which included a consent form, stated that patients could withdraw consent for the home visit, that they would be part of the decision-making process, and that they could request a copy of the report. One leaflet had a clear structure (score 3/5). Two clearly stated the aims of the information leaflet (score 3/5).

None of the information leaflets provided unbiased and detailed information about options, presented probabilities of outcomes in an understandable way, helped patients to make appropriate decisions, contained accurate information, provided specific information regarding disclosure of conflicts of interest, or enabled the reader to judge the reliability of the information within the leaflet (score 0 to 2). Only three of the leaflets made any specific reference to social issues.

SMOG Readability Formula: The information leaflets had a mean readability of 10th grade (Table 3). The scores ranged from 8th to 12th grade.


In the UK, government policy has emphasised the importance of high quality information to assist patients to make health care choices and to share in decisions about treatment and care (Department of Health 2007). Despite the low response rate, this study raises concerns about the quality of home visit information leaflets provided to older adults in acute care, and about the usefulness of these home visit information leaflets in enabling older people to make informed health care choices together with their occupational therapist.

Occupational therapists should be mindful of the special needs of older adults when designing information leaflets. This research found that just three of the information leaflets analysed had been specifically designed for older adults. This proportion is similar to that in the research by Sharry et al (2002), which found that only half of the materials provided for older adults were designed with this client group in mind. Furthermore, in the present study only three of the leaflets presented information about the home visit process. All of the information leaflets had low scores in relation to providing unbiased and detailed information about options, presenting probabilities of outcomes in an understandable way and helping patients to make appropriate decisions. The importance of interventions supported by best evidence is crucial in occupational therapy. However, similarly to this study, Sharry et al (2002) found that written information designed by therapists did not emphasise the importance of evidence-based information for clients.

The present study found that the reading level of the home visit information leaflets was on average four grades higher than the recommended level of 5th/6th grade (Griffin et al 2006, Marshall and Williams 2006). This is of concern because Winslow (2001) suggested that ease of reading is of no value if the quality of content of information is not of a good standard. Thus the accuracy, relevance and tone of the information should also be considered, as well as how it is presented (Winslow 2001). In addition, effective information needs to be written at the correct level, so that patients can read and understand it. It also needs to contain information from the patient's viewpoint (Clerehan et al 2005). The findings of the present study correspond with the occupational therapy study by Griffin et al (2006), who found a mismatch between the reading level of occupational therapy education materials and older adults' reading ability. This is an issue because limited health literacy appears to be more common amongst older adults (Baker et al 2000, Chew et al 2004). On the other hand, the knowledge and ability of participants aged 65 and over can be improved when reading leaflets reflect content and design principles (McKenna and Scott 2007).

Limitations of the study: The primary limitation of this study is its poor response rate. This may be because therapists were recruited using trust websites, or because therapists were not using any information leaflet. Therapists may have been reluctant to send information leaflets that would be critiqued in fear of a negative result.


Within occupational therapy, very little research has examined the quality or value of information leaflets. This research has highlighted the need for occupational therapy information leaflets to meet recommended quality standards if they are to be of any value within occupational therapy practice. Information leaflets should acknowledge that the patient has a decision to make. In this instance, acute inpatients can decide whether to accept the home visit as an occupational therapy intervention. Indeed, within the information leaflet it would be expected that both the risks and the benefits are explained, as well as describing the actual home visit process. Following this research, the authors aim to work with the College of Occupational Therapists Specialist Section--Older People, therapists and older adults and their carers to devise an evidence-based information leaflet that can be used nationally throughout the UK.

Conflict of interest: None declared.

Key findings

* Occupational therapy information leaflets need to meet recommended quality standards.

* They need to be evidence based, and to explain both the risks and the benefits of home visits.

What the study had added

This study is the first in the UK to evaluate information leaflets for older adults in occupational therapy. It adds new knowledge regarding the quality of information leaflets used by occupational therapists during the home visit process.


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Anita Atwal, (1) Alexandra Luke (2) and Nicola Plastow (3)

(1) Senior Lecturer in Occupational Therapy, Director of the Centre for Professional Practice Research, School of Health Sciences and Social Care, Brunel University, West London.

(2) Head of Clinical Pathways--Neurosciences, Maudsley Hospital, London.

(3) Lecturer in Occupational Therapy, School of Health Sciences and Social Care, Brunel University, West London.

Corresponding author: Dr Anita Atwal, Senior Lecturer in Occupational Therapy, School of Health Sciences and Social Care, Brunel University, Mary Seacole Building, Uxbridge, Middlesex UB8 3PH. Email: anita.atwal@brunel.ac.uk

DOI: 10.4276/030802211X13125646370889
Table 1. Checklist used to develop questions for the internet email

Involve experts and using good evidence. (1-3)

Provide balanced information and all relevant details. (1-4)

Ensure the information needs of the target audience. (1-4)

Ensure currency by including publication date and regularly
reviewing and updating. (1-4)

Involve users in the development and evaluation of the text. (1-3)

(1) Griffin et al (2003); (2) Hoffmann and Worrall (2004); (3)
Marshall and Williams (2006); (4) National Health Service (2010).

Table 2. Score of raters for each component of the International

Leaflet     Starts with       Provides
number          clear         unbiased
              statement          and
                of aims       detailed

              5 points        5 points

            R1      R2      R1      R2
One          3       3       2       2
Two          0       0       1       1
Three        1       1       1       1
Four         2       2       1       1
Five         3       3       1       1

Table 3. SMOG readability level scores of the home visit
information leaflets

Leaflet      Rater 1, SMOG        Rater 2, SMOG
number     readability level    readability level
                (grade)              (grade)

One               12th                 12th
Two               11th                 11th
Three             10th                 9th
Four              10th                 10th
Five              10th                 11th

Patient Decision Aids Standards (IPDAS)

      Presents           Helps       Contains     Discloses
   probabilities of     patients     accurate    conflicts of
    outcomes in an      to make     information    interest
    understandable    appropriate
         way           decisions

       5 points      5 points         5 points     5 points

 R1     R1     R3     R1     R2     R1     R2     R1     R2

 2      1      1      2      2      0      0      0      0
 0      0      0      0      0      0      0      0      0
 0      0      0      1      2      0      0      1      1
 0      0      0      1      1      0      0      0      0
 0      0      0      1      1      0      0      0      0

     Has a clear           Helps the       Discusses    Total
      structure          reader judge        social     score
      and layout        its reliability      issues

       5 points             5 points        1 bonus

 R1     R1     R3     R1     R1     R3     R1     R2

 3      4      3      2      1      1      1      1      13
 1      1      1      2      2      2      0      0      4
 2      2      1      1      1      1      1      1      8
 1      1      1      0      0      0      0      0      5
 2      2      2      1      1      2      1      1      9
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