Background: Awareness of chronic kidney disease (CKD) is suboptimal among patients with CKD, perhaps due to poor readability of patient education materials (PEMs). We reviewed the suitability and readability of common PEMs that focused on 5 content areas: basics of CKD, risk factors for CKD development, risk factors for CKD progression, complications of CKD and self-management strategies to improve kidney health. Methods: Three reviewers (nephrologist, primary care physician, patient) used the Suitability Assessment of Materials to rate PEMs on message content/stimulation of learning, typography, visuals and layout and determined literacy level. Mean ratings were calculated for each PEM by content area and overall (superior = 70-100; adequate = 40-69; inadequate = <40). Linear regression was used to determine the impact of literacy level on mean rating. Results: We reviewed 69 PEMs from 19 organizations, divided into 113 content area sections. Most (79%) PEM sections were ‘adequate' (mean rating, 58.3%). Inclusion of patient-centered content and opportunities for patient interaction were associated with ‘superior' ratings. Mean ratings (SD) were similar across content areas: basics of CKD, 58.9% (9.1); risk factors for CKD development, 57.0% (12.3); risk factors for CKD progression, 58.5% (12.0); CKD complications, 62.3% (15.7), and self-management strategies, 62.2% (12.3). ≤6th grade literacy level (vs. >6th grade) was associated with an 11.7 point higher mean rating. Conclusion: Most PEMs for kidney disease were adequate. Outstanding PEMs shared characteristics of patient centeredness, a low literacy level, and patient interaction. Providers should be aware of strengths and limitations of PEMs when educating their patients about CKD.

1.
Coresh J, Byrd-Holt D, Astor BC, Briggs JP, Eggers PW, Lacher DA, Hostetter TH: Chronic kidney disease awareness, prevalence, and trends among U.S. adults, 1999 to 2000. J Am Soc Nephrol 2005;16:180-188.
2.
Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY: Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004;351:1296-1305.
3.
Barrett BJ: Applying multiple interventions in chronic kidney disease. Semin Dial 2003;16:157-164.
4.
Sarnak MJ, Greene T, Wang X, Beck G, Kusek JW, Collins AJ, Levey AS: The effect of a lower target blood pressure on the progression of kidney disease: long-term follow-up of the modification of diet in renal disease study. Ann Intern Med 2005;142:342-351.
5.
Nissenson AR, Collins AJ, Hurley J, Petersen H, Pereira BJ, Steinberg EP: Opportunities for improving the care of patients with chronic renal insufficiency: current practice patterns. J Am Soc Nephrol 2001;12:1713-1720.
6.
Costantini L, Beanlands H, McCay E, Cattran D, Hladunewich M, Francis D: The self-management experience of people with mild to moderate chronic kidney disease. Nephrol Nurs J 2008;35:147-155, quiz 156.
7.
Plantinga LC, Tuot DS, Powe NR: Awareness of chronic kidney disease among patients and providers. Adv Chronic Kidney Dis 2010;17:225-236.
8.
Tuot DS, Plantinga LC, Hsu CY, Jordan R, Burrows NR, Hedgeman E, Yee J, Saran R, Powe NR: Chronic kidney disease awareness among individuals with clinical markers of kidney dysfunction. Clin J Am Soc Nephrol 2011;6:1838-1844.
9.
Wright Nunes JA, Wallston KA, Eden SK, Shintani AK, Ikizler TA, Cavanaugh KL: Associations among perceived and objective disease knowledge and satisfaction with physician communication in patients with chronic kidney disease. Kidney Int 2011;80:1344-1351.
10.
Hostetter TH, Lising M: National kidney disease education program. J Am Soc Nephrol 2003;14:S114-116.
11.
Kutner M, Greenberg E, Jin Y, Paulsen C: The health literacy of America's adults: results from the 2003 national assessment of adult literacy (NCES 2006-483). Washington, National Center for Educational Statistics, US Department of Education, 2006.
12.
Fraser SD, Roderick PJ, Casey M, Taal MW, Yuen HM, Nutbeam D: Prevalence and associations of limited health literacy in chronic kidney disease: a systematic review. Nephrol Dial Transplant 2013;28:129-137.
13.
Calderon JL, Zadshir A, Norris K: Structure and content of chronic kidney disease information on the World Wide Web: barriers to public understanding of a pandemic. Nephrol News Issues 2004;18:76, 78-79, 81-74.
14.
Doak CC, Doak LG, Root JH: Teaching Patients with Low Literacy Skills, ed 2. Philadelphia, JB Lippincott, 1996.
15.
Taylor-Clarke K, Henry-Okafor Q, Murphy C, Keyes M, Rothman R, Churchwell A, Mensah GA, Sawyer D, Sampson UK: Assessment of commonly available education materials in heart failure clinics. J Cardiovasc Nurs 2012;27:485-494.
16.
Lee TW, Kang SJ, Kim HH, Woo SR, Kim S: Suitability and readability assessment of printed educational materials on hypertension (in Korean). J Korean Acad Nurs 2011;41:333-343.
17.
Hoffmann T, Ladner Y: Assessing the suitability of written stroke materials: an evaluation of the interrater reliability of the suitability assessment of materials (SAM) checklist. Top Stroke Rehabil 2012;19:417-422.
18.
Kirsch I, Jungeblut A, Jenkins L: Adult literacy in America: a first look at the results of the national adult literacy survey. Washington, Department of Education, 1993.
19.
Wang LW, Miller MJ, Schmitt MR, Wen FK: Assessing readability formula differences with written health information materials: application, results, and recommendations. Res Social Adm Pharm 2012, E-pub ahead of print.
20.
Fagerlin A, Rovner D, Stableford S, Jentoft C, Wei JT, Holmes-Rovner M: Patient education materials about the treatment of early-stage prostate cancer: a critical review. Ann Intern Med 2004;140:721-728.
21.
Vallance JK, Taylor LM, Lavallee C: Suitability and readability assessment of educational print resources related to physical activity: implications and recommendations for practice. Patient Educ Couns 2008;72:342-349.
22.
Seligman HK, Wallace AS, DeWalt DA, Schillinger D, Arnold CL, Shilliday BB, Delgadillo A, Bengal N, Davis TC: Facilitating behavior change with low-literacy patient education materials. Am J Health Behav 2007;31(suppl 1):S69-S78.
23.
Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A: Improving chronic illness care: translating evidence into action. Health Aff (Millwood) 2001;20:64-78.
24.
Bodenheimer T, Wagner EH, Grumbach K: Improving primary care for patients with chronic illness: the chronic care model. 2. JAMA 2002;288:1909-1914.
25.
Mancuso CA, Sayles W, Robbins L, Allegrante JP: Novel use of patient-derived vignettes to foster self-efficacy in an asthma self-management workbook. Health Promot Pract 2010;11:44-53.
26.
Mancuso CA, Sayles W, Allegrante JP: Randomized trial of self-management education in asthmatic patients and effects of depressive symptoms. Ann Allergy Asthma Immunol 2010;105:12-19.
27.
Bischoff EW, Hamd DH, Sedeno M, Benedetti A, Schermer TR, Bernard S, Maltais F, Bourbeau J: Effects of written action plan adherence on COPD exacerbation recovery. Thorax 2011;66:26-31.
28.
Naik AD, Palmer N, Petersen NJ, Street RL Jr, Rao R, Suarez-Almazor M, Haidet P: Comparative effectiveness of goal setting in diabetes mellitus group clinics: randomized clinical trial. Arch Intern Med 2011;171:453-459.
29.
Bodenheimer T, Handley MA: Goal-setting for behavior change in primary care: an exploration and status report. Patient Educ Couns 2009;76:174-180.
30.
Paivio A: Mental Representations: A Dual Coding Approach. New York, Clarendon Press, 1986.
31.
Hawley ST, Zikmund-Fisher B, Ubel P, Jancovic A, Lucas T, Fagerlin A: The impact of the format of graphical presentation on health-related knowledge and treatment choices. Patient Educ Couns 2008;73:448-455.
32.
Tait AR, Voepel-Lewis T, Zikmund-Fisher BJ, Fagerlin A: The effect of format on parents' understanding of the risks and benefits of clinical research: a comparison between text, tables, and graphics. J Health Commun 2010;15:487-501.
33.
You WB, Wolf MS, Bailey SC, Grobman WA: Improving patient understanding of preeclampsia: a randomized controlled trial. Am J Obstet Gynecol 2012;206:431 e431-e435.
34.
Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K: Low health literacy and health outcomes: an updated systematic review. Ann Intern Med 2011;155:97-107.
35.
Schillinger D, Barton LR, Karter AJ, Wang F, Adler N: Does literacy mediate the relationship between education and health outcomes? A study of a low-income population with diabetes. Public Health Rep 2006;121:245-254.
36.
Schillinger D, Grumbach K, Piette J, Wang F, Osmond D, Daher C, Palacios J, Sullivan GD, Bindman AB: Association of health literacy with diabetes outcomes. JAMA 2002;288:475-482.
37.
Peterson PN, Shetterly SM, Clarke CL, Bekelman DB, Chan PS, Allen LA, Matlock DD, Magid DJ, Masoudi FA: Health literacy and outcomes among patients with heart failure. JAMA 2011;305:1695-1701.
38.
Williams MV, Baker DW, Parker RM, Nurss JR: Relationship of functional health literacy to patients' knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern Med 1998;158:166-172.
39.
Cavanaugh KL, Wingard RL, Hakim RM, Eden S, Shintani A, Wallston KA, Huizinga MM, Elasy TA, Rothman RL, Ikizler TA: Low health literacy associates with increased mortality in ESRD. J Am Soc Nephrol 2010;21:1979-1985.
40.
Grubbs V, Gregorich SE, Perez-Stable EJ, Hsu CY: Health literacy and access to kidney transplantation. Clin J Am Soc Nephrol 2009;4:195-200.
41.
Green JA, Mor MK, Shields AM, Sevick MA, Arnold RM, Palevsky PM, Fine MJ, Weisbord SD: Associations of health literacy with dialysis adherence and health resource utilization in patients receiving maintenance hemodialysis. Am J Kidney Dis 2013;62:73-80.
42.
Osborn CY, Paasche-Orlow MK, Bailey SC, Wolf MS: The mechanisms linking health literacy to behavior and health status. Am J Health Behav 2011;35:118-128.
43.
Wright-Nunes JA, Luther JM, Ikizler TA, Cavanaugh KL: Patient knowledge of blood pressure target is associated with improved blood pressure control in chronic kidney disease. Patient Educ Couns 2012;88:184-188.
44.
Bodenheimer T, Lorig K, Holman H, Grumbach K: Patient self-management of chronic disease in primary care. JAMA 2002;288:2469-2475.
45.
Partin MR, Nelson D, Radosevich D, Nugent S, Flood AB, Dillon N, Holtzman J, Haas M, Wilt TJ: Randomized trial examining the effect of two prostate cancer screening educational interventions on patient knowledge, preferences, and behaviors. J Gen Intern Med 2004;19:835-842.
46.
Muthusamy AD, Leuthner S, Gaebler-Uhing C, Hoffmann RG, Li SH, Basir MA: Supplemental written information improves prenatal counseling: a randomized trial. Pediatrics 2012;129:e1269-e1274.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.