Introduction

The prevalence of HIV infections has increased rapidly in recent years in the UK. In 2006, it was estimated that a total of 73,000 people were infected with HIV, with a further new 6,393 cases reported in 2007 (Health Protection Agency 2007). The epidemiology of HIV infection has changed over the years. In the mid-1980s, the three groups of people considered to be at the highest risk of HIV infection were men who have sex with men, injection drug users and those who have received blood products (e.g. through blood transfusions). However, since 1999, the majority of new infections have been reported among heterosexuals (Health Protection Agency 2007). The prognosis for HIV-infected individuals has improved over the past ten years. Although there is currently no vaccine and no cure for HIV, HAART (Highly Active Antiretroviral Therapy) has proven highly effective in delaying the onset of AIDS and lengthening the lifespan of infected individuals (Rutland et al. 2007).The increased prevalence of HIV infections in the UK means that healthcare professionals in all settings are more likely to care for patients with HIV than in past years.

A number of studies have been conducted worldwide to examine healthcare professionals’ knowledge and/or attitudes to HIV in countries including the UK (Tierney 1995; Laraqui et al. 2002; Pisal et al. 2007). Findings showed that healthcare workers are frequently fearful, negative, ill-informed and discriminatory towards HIV-positive patients. Furthermore, fears regarding perceived risks when caring for parents with HIV may hamper quality of patient care (Pisal et al. 2007). As a result, HIV-positive patients may experience stigma and dehumanisation, together with feelings of isolation and guilt. There is an unmet need for effective education programmes to increase healthcare professionals’ knowledge about HIV, modes of transmission and precautions that should be taken when caring for HIV-positive patients. Studies have shown that education programmes to increase levels of knowledge among nurses significantly reduced fears about interacting with HIV-positive patients (Pisal et al. 2007).

This paper discusses the development of an educational leaflet aimed at healthcare professionals, analyses the methodology used and evaluates the leaflet and the process of development.

Leaflet development

When devising health promotion and education programmes, the three main components which must be considered are planning, implementation and evaluation and it may be helpful to use a health promotion model in this process (Whitehead 2003). The Ewles and Simnett model (1992) proposes five different ways of considering health promotion which include a medical approach, behaviour change approach, educational change approach, client-centred approach and social change approach. Our health education approach best fit the educational and behavioural change approaches. By educating the target group of individuals, the knowledge they gain will empower them to make informed decisions and will act as an important influencer on their behaviour (Aghamolaei et al. 2005). In their model, Ewles and Simnett identified 9 stages which were used in the planning of the health education initiative discussed in this paper and which include:

1. Identification of the target group
2. Identification of the needs of the target group
3. Establishment of the goals of education
4. Formulation of specific objectives
5. Identification of resources
6. Planning of content and method
7. Planning of methods of evaluation
8. Implementation of education
9. Evaluation of effectiveness.

Planning

The target group for this health education strategy was healthcare support workers who may come into contact with clients infected with HIV or AIDS. As discussed, there is a clear need for education programmes for healthcare professionals who may have contact with HIV-positive clients. The main goals of this strategy were to increase levels of knowledge about HIV with a view to reducing fears and stigma surrounding HIV-positive individuals, and alleviate any existing misconceptions surrounding the spread of the HIV virus in clinical practice. The approach taken in this strategy was to develop an educational information leaflet. Previous research has demonstrated that leaflets that promote knowledge of HIV are effective in reducing fear and anxiety among healthcare workers, while also increasing overall knowledge of the disease (Pisal et al. 2007). Leaflets have been shown to provide a number of benefits. For example, they can be used to re-enforce information delivered verbally and can deliver a greater volume of information that via verbal communication alone (Secker 1997). Furthermore, leaflets may be retained for future reference and can be shared with others. However, there is evidence to suggest that health promotion leaflets needs to be carefully designed, since not all leaflets communicate their messages effectively to their target audience (Shire Hall Communications 1992).

Methodology

Sources of information

Information on the HIV was sourced by searching the Pubmed electronic database and Department of Health websites. Up-to-date, high-quality publications were selected where possible. The Health Protection Agency websites was also search for recent UK-specific epidemiology data. Information relating to the design of the leaflet was gathered from both Pubmed and Google searches. All information sourced was read carefully, findings were accurately summarised and key points were highlighted.

Leaflet design

The design of educational leaflets should assist the reader’s understanding of the content within (Secker 1997). The leaflet title was chosen carefully so as to be appealing and encourage readers to want to read the entire leaflet. A design theme was chosen which was applied consistently throughout each of the pages. Black and red text was used against a yellow background which demonstrated good readability and made the leaflet stand out on the shelf among a group of other leaflets. The choice of colours was designed to reflect a ‘danger/hazard’ theme which was intended to motivate the reader. While it could be argued that the association of red with danger may actually re-enforce existing negative beliefs about HIV, we believe that our choice of a strong and positive leaflet title negates this possibility.

The Times New Roman font in a 12 point size was used for the main text. Research suggests that this is one of the best fonts for educational materials, and that a 12 point font size is the minimum size for readers without visual impairment (Secker 1997). Although it is acknowledged that using a font size as large as this limits the amount of text that can be accommodated, a shortcoming of many educational leaflets is that they contain text which is too small to read comfortably (Albert and Chadwick 1992).

The images used in the leaflet were relevant to the content. Research has shown that the use of illustrations is an important factor to consider in leaflet design and that illustrations should always be informative and relative to the content of the leaflet, otherwise they will detract from the information being conveyed (Rohret and Ferguson 1990; Albert and Chadwick 1992). By using ‘before’ and ‘after’ versions of similar images, we aimed to convey some of the feelings that HIV-positive clients may experience in healthcare settings and how a change in the behaviour and attitude of healthcare workers can have a positive impact on the client’s experience as well as improving the interaction between the client and care provider. Another important factor which must be considered when using images, pictures and other illustrative materials is their source and whether there are copyright issues associated with their use. Unfortunately, we did not consider the legal implications associated with our choice of illustration, which subsequently prevented the leaflet from being distributed to the target audience.

A folded one third A4 size leaflet, printed on yellow paper with a gloss finish was chosen. This is a popular choice of size for educational leaflets and provides good portability, being small enough to put in a bag. The use of folding negates the need for staples which add to cost.

[Client: you didn’t mention anything about leaflet size, stock of paper or finish so I’ve added in what I have found from my own experience of designing educational materials, although I’m not sure of the exact stock of paper that would be the best for a leaflet of this description and no papers discuss this

]

Language

According to Bennett and Heller (2006),

“


Speaking the language of the audience is crucial in attempting to appeal to them and change their understanding of any issue”.

The language in this leaflet used simple terminology that is easily understood and is jargon free, two factors which have been shown to be of importance in educational materials (Ewles and Simnett 2003). Personal and colloquial terms were used which were designed to engage the reader and encourage critical thinking and reflection of their own clinical practice. The use of personal pronouns has previously been shown to be effective in making the reader feel that the leaflet is addressing them directly, thereby making it more appealing (Glasper and Burge 1992; Albert and Chadwick 1992).

The use of long words was limited and sentences were generally short and succinct, with each attempting to explain a single idea (Manning 1981). Evidence has shown that this facilitates the integration and storage of information into memory. This is an important factor since the cognitive load theory proposes that redundant forms of information may require longer processing and may prevent the reader from learning (Doak et al. 1996). Research has also demonstrated that the more long words and long sentences used, the more difficult the leaflet will be for the reader to understand (Pastore and Berg 1987; Bernier and Yasko 1991). Simplicity in both choice of language and sentence structure is also of value if the leaflet were to be translated into other languages or into Braille. While this leaflet was only designed for target groups within the UK, it could also be translated successfully if required.

Readability may be assessed more accurately by performing a readability test to determine the reading age of any written material. These tests typically relate the number of long words and sentences to the reading age necessary to understand the materials. Evidence shows that the reading age of the majority of adults in many developed countries is 10-14 years (Vahabi and Ferris 1995). Although we did not employ a readability test when developing this leaflet, it is an activity that would have been helpful to confirm the readability of the material we had developed and would be particularly valuable when developing patient educational materials where reading age would be of greater importance.

Content and organisation of information

It is important that educational materials are accurate and up to date (Secker 1997). As previously discussed, the most recent information was selected for inclusion in our leaflet. Summarised information was discussed for suitability and then reviewed for accuracy by several members of the team as a quality control exercise. The content of this leaflet is quite specific and should be applicable for the foreseeable future, unless a vaccine or cure for HIV/AIDS is developed or there are changes to universal precautions. Nonetheless, it may have been worth including a publication date on the leaflet to enable the reader to quickly see how old the leaflet is and if a more up-to-date version may be available.

The organisation of text within the leaflet is a very important factor influencing whether the material makes sense to the reader (Secker 1997). Studies have shown that educational information should be presented in a way that reflects the priorities of the reader (Bernier and Yasko 1991). Therefore, paragraphs of text were arranged so that the most important and relevant facts were discussed first. This arrangement has been shown to facilitate the assimilation of information and re-enforce learning (Manning 1981). Sequential lists of bullet points were used to present the text included in the leaflet. These have also been shown to enhance assimilation, when compared with blocks of bulk information delivered in a narrative form (Manning 1981). Key points within the text were emphasised in bold type since the use of colour has shown to be ineffective (Kitching 1990) and a number of colours were already employed in the design theme. The text in the leaflet was justified which is not in line with the recommendation of unjustified, left-aligned text using indentations for ease of readability (Kitching 1990).

[Client: you don’t mention whether headings were used in the leaflet. Sentence case headings in bold type placed again


st the left-hand margin with plenty of space around are effective in standing out from the main text and will assist the reader in quickly locating the information they require within the leaflet (Dixon and Park, 1990) Reference: Dixon, E. & Park, R. 1990,


‘Do patients understand written health information?’, Nursing Outlook, vol. 38, no. 6, pp. 278-81

.]

Evidence has shown that leaflets should convey only essential information and contain references to further reading in a separate section (Vahabi and Ferris 1995). In our leaflet, the name of the first author and the year were included in the text as citations for source references. For a more continuous flow, it may have been better to replace the author name with a superscript number which relates to the full reference which would be included in a reference list at the end of the leaflet. Since this leaflet is aimed at healthcare professionals who aim to use research-based evidence to inform best practice, it would be particularly important to include the sources of the reference materials to encourage further reading; however, due to space constraints, we were not able to include this reference list in our leaflet.

Implementation

The leaflet has not been distributed to the intended target group due to legal implications surrounding the images used. The original implementation plan included: (1) distribution of the leaflet after infection control study days held within the hospital, or at study sessions focussing on HIV/AIDS as a method of re-enforcing the verbal information already delivered; (2) inclusion of the leaflet as part of the induction package for relevant new members of staff; and (3) inclusion of leaflets on stands already located in hospital common rooms or other venues.

Evaluation

As discussed above, since the leaflet has not been distributed to the target audience, it has not been possible to evaluate the success of our approach. We planned to pilot our leaflet to a selected group of healthcare support workers and gain feedback both verbally and via the use of a questionnaire designed to address the quality of content, readability and use of language within the leaflet. Gaining preliminary feedback on the leaflet may have helped us to address any issues identified prior to implementation.

The specific limitations identified in our leaflet have already been discussed within the relevant sections of this paper. However, when reflecting on our approach to producing this leaflet, we were able to identify a number of other areas where we feel that the process could be improved in the future: (1) experimenting with other colours may make the leaflet aesthetically more appealing; (2) including the address of the charity listed, instead of just the website, would enable those individuals without internet facilities to also access this valuable resource more easily; (3) when searching for published literature on knowledge and attitudes of healthcare professionals to HIV, although many studies were identified, there were few recent studies conducted within the UK. For this reason, it may have been worth considering designing a preliminary questionnaire to gather the attitudes and beliefs of the healthcare workers within our particular setting to ensure that we were designing a leaflet which addressed their specific needs; and (4) we believe that the use of an interactive tool, such as a quiz, would further engage the target audience, serving to re-enforce and challenge what they have learnt from the leaflet.

Conclusions

Our leaflet met the majority of published criteria for well-designed educational material, in terms of content, language and design. The leaflet contained up-to-date, accurate information which was relevant to the target audience. The overall look and feel of the leaflet was appealing and uncrowded with good readability, while the use of relevant images helped to convey the important messages contained within the leaflet. The major limitation of our methodology was the use of images with surrounding legal implications which prevented the leaflet from being distributed. This made is impossible to evaluate the success of our approach which was very disappointing. Nonetheless, developing this leaflet has provided valuable experience which can be applied when designing similar health promotion and education programmes in the future.

Bibliography

Aghamolei, T., Eftekhar, H., Mohammed, K., Nahjavani, M., Shojaeizadeh, D., Ghofranipour, F., Safa, O. 2005, ‘Effects of a health education program on behaviour, HbA1c and health-related quality of life in diabetic patients’,

Acta Medica Iranica

, vol. 43, no. 2, pp. 89-94.

Albert, T. & Chadwick, S. 1992, ‘How readable are practice leaflets?’,

British Medical Journal,

vol. 305, pp. 1266-8.

Bennett and Heller 2006, Design studies: theory and research in graphic design, Princeton Architectural Press, New York.

Bernier, M. J. & Yasko, J. 1991,‘Designing and evaluating printed education materials: model and instrument development’,

Patient Education and Counseling

, vol. 18, pp. 253-63.

Doak, C. C,, Doak L. G., Root, J. H. 1996,

Teaching patients with low literacy skills

, 2nd ed, Lippincott Williams & Wilkins, Philadelphia.

Ewles and Simnett 1992,

Promoting Health: a practical guide

. 2nd ed, Scutari Press, London.

Ewles and Simnett 2003,

Promoting Health: a practical guide

. 5th ed, Scutari Press, London.

Ezedinachi, E., Ross, M. W., Meremiku, M., Essien, E. J., Edem, C. B., Ekure, E., Ita, O. 2002,“The impact of an intervention to change health workers’ HIV/AIDS attitudes and knowledge in Nigeria: a controlled trial’, Public Health, vol. 116, pp. 106-12

Glasper, A. & Burge, D. 1992, ‘Developing family information leaflets’,

Nursing Standard

, vol. 6, no. 25, pp. 24-7.

Health Protection Agency 2007,

Testing Times: HIV and other sexually transmitted infections in the United Kingdom, 2007

. Retrieved 31

^st

July 2008 from:

http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1203084355941

Kitching, J. B. 1990, ‘Patient information leaflets – the state of the art’,

Journal of the Royal Society of Medicine

, vol. 83, pp. 298-300.

Pisal, H., Sutar, S., Sastry, J., Kapadia-Kundu, N., Joshi, A., Joshi, M., Leslie, J., Scotti, L., Bharucha, K., Suryavanshi, N., Phadke, M., Bollinger, R., Shankar, A.V. 2007, ‘Nurses’ health education program in India increases HIV knowledge and reduces fear’,

Journal of the Association of Nurses and AIDS Care

, vol. 18, no. 6, pp. 32-43.

Laraqui, C. H., Tripodi, D., Rahhali, A., Bichara, M., Laraqui, S., Curtes, J. P., Verger, C., Zahraoui, M. 2002,’Knowledge, practice, and behaviour of healthcare workers confronted to AIDS and the occupational risk of HIV transmission in Morocco,

Medecine et Maladies Infectieuses

, vol. 32, pp. 307-14.

Manning, D. 1981, ‘Writing readable health messages’,

Public Health Reports

, vol. 96, no. 5, pp. 464-5.

Pastore, P. & Berg, B. 1987, ‘The evaluation of patient education materials: focus on readability’,

Patient Education and Counseling

, vol. 9, no. 2, pp. 216-9.

Rohret, L. & Ferguson, K. J. 1990, ‘Effective use of patient education illustrations’,

Patient Education and Counseling

, vol. 15, pp. 73-5.

Rutland, E., Foley, E., O’Mahony, C., Miller, M., Maw, R., Kell, P., Rowen, D. 2007, ‘How normalised is HIV care in the UK? A survey of current practice and opinion’,

Sexually Transmitted Infections

, vol. 83, pp. 151-4.

Secker, J. 1997, ‘Assessing the quality of patient education leaflets’,

Coronary Health Care

, vol. 1, pp. 37-41.

Shire Hall Communications 1992,

Consumer leaflets – a write off?

, Shire Hall Communications, London.

Tibdewel, S. S. & Wadhva, S. K. 2001, ‘HIV/AIDS awareness among hospital employees’,

Indian Journal of Medical Science

, vol. 55, no. 2, pp. 69-72.

Vahabi, M. & Ferris, L. 1995, ‘Improving written patient education materials: a review of the evidence’,

Health Education Journal

, vol. 54, pp. 99-106.

Whitehead, D. 2003, ‘Evaluating health promotion: a model for nursing practice’,

Journal of Advanced Nursing

, vol. 41, no. 5, pp. 490-8.