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Published on 08.10.15 in Vol 4, No 4 (2015): Oct-Dec

Preprints (earlier versions) of this paper are available at http://preprints.jmir.org/preprint/4583, first published Apr 27, 2015.

This paper is in the following e-collection/theme issue:

    Original Paper

    Feasibility of Two Educational Methods for Teaching New Mothers: A Pilot Study

    1University of Louisville, School of Nursing, Louisville, KY, United States

    2University of Louisville Hospital, Louisville, KY, United States

    3University of Louisville, Department of Pediatrics, Louisville, KY, United States

    4Center for Women and Infants, University of Louisville Hospital, Louisville, KY, United States

    5University of Louisville, Louisville, KY, United States

    *these authors contributed equally

    Corresponding Author:

    M Cynthia Logsdon, PhD, RN, FAAN

    University of Louisville

    School of Nursing

    555 S. Floyd Street

    HSC

    Louisville, KY, 40202

    United States

    Phone: 1 5028525825

    Fax:1 5028528786

    Email:


    ABSTRACT

    Background: Printed health educational materials are commonly issued to prepare patients for hospital discharge. Teaching methods that engage multiple senses have been shown to positively affect learning outcomes, suggesting that paper materials may not be the most effective approach when educating new mothers. In addition, many written patient educational materials do not meet national health literacy guidelines. Videos that stimulate visual and auditory senses provide an alternative, potentially more effective, strategy for delivering health information. The acceptability of these methods, as perceived by nurses executing patient education initiatives, is important for determining the most appropriate strategy.

    Objective: The purpose of this study was to determine the feasibility of 2 educational methods for teaching new mothers how to care for themselves and their infants after hospital discharge. Feasibility was measured by adequate enrollment, acceptability of the intervention to patients and nurses, and initial efficacy.

    Methods: New mothers (n=98) on a Mother-Baby Unit received health information focused on self-care and infant care delivered as either simple printed materials or YouTube videos on an iPad. Mothers completed a pretest, post-test, and an acceptability survey. Following completion of the initiative, nurses who participated in delivering the health education using one of these 2 methods were asked to complete a survey to determine their satisfaction with and confidence in using the materials.

    Results: Mothers, on average, were 26 years old; 72% had a high school education; and 41% were African American. The improvement in knowledge scores was significantly higher for the iPad group (8.6% vs 4.4%, P=.02) compared to the pamphlet group. Group (B=4.81, P=.36) and time (B=6.12, P<.001) significantly affected scores, while no significant interaction effect was observed (B=5.69, P=.09). There were no significant differences in responses between the groups (all P values >.05). The nurses had a mean age of 44.3 years (SD 13.9) and had, on average, 16.6 years of experience (SD 13.8). The nurses felt confident and satisfied administering both educational modalities.

    Conclusions: The pamphlet and iPad were identified as feasible and acceptable modalities for educating new mothers about self-care and infant care, though the iPad was more effective in improving knowledge. Understanding the acceptability of different teaching methods to patient educators is important for successful delivery of informational materials at discharge.

    Interact J Med Res 2015;4(4):e20

    doi:10.2196/ijmr.4583

    KEYWORDS



    Introduction

    Background

    International health care providers have long acknowledged the importance of sharing health information with patients/consumers. In no population group is education more important than childbearing women and their families [1]. The World Health Organization recommends that essential health content be taught to pregnant and parenting women to protect their health and that of their babies (eg, postnatal recovery, care of the newborn, promotion of early exclusive breastfeeding, and assistance with deciding on future pregnancies to improve pregnancy outcomes) [1]. However, childbearing women frequently have difficulty interpreting and operationalizing information, and health education may not translate into appropriate health behaviors [2].

    In the United States, emphasis on health education for all patient groups is unprecedented. The Affordable Care Act encourages patients to take control of their health care decisions based upon the latest evidence [3]. In the acute care setting, national organizations such as the Agency for Healthcare Research and Quality, American Medical Association, Centers for Medicare and Medicaid Services, and Patient-Centered Outcomes Research Institute stress the need for effective health education for hospitalized patients and an evaluation of health education is included in hospital accreditation procedures [4]. Soon, reimbursement to acute care settings will be based upon such quality measures.

    Testing innovative methods for teaching new mothers, with attention to health literacy levels of the population, should be guided by efforts to improve state maternal child health statistics [5-7]. Kentucky has one of the lowest literacy rates in the United States with 14% of adults 16-65 years of age, on average, having very little to no literacy skills and another 26% having low literacy skills [8]. Simultaneously, the rate of substantiated cases of child abuse in Kentucky is 16.6 per 1000 children, compared to the US rate of 9.1 in 2011 [9]. Traumatic brain injury is the leading cause of death for children and 64% of cases are from abuse [10]. The US has a higher rate of fatalities from child abuse and neglect than any other higher income country and Kentucky has ranked among the states with the highest rate over recent years [11]. Kentucky is currently ranked 8th among all states for child abuse fatalities [11]. Breastfeeding statistics from Kentucky are also poorer than the US average for all indicators including rates of ever breastfeeding (United States 77% vs Kentucky 59%), breastfeeding at 6 months (47% vs 27%), breastfeeding at 12 months (26% vs 11%), exclusive breastfeeding at 3 months (36% vs 21%), and exclusive breastfeeding at 6 months (16% vs 10%) [12]. Rates of postpartum depression, which have an adverse impact on development of both the mother and infant, are greater than or equal to national rates in Kentucky. Poverty is a risk factor for all of these and many other threats to women and children’s health [13-19]. These data suggest that innovative methods for teaching new mothers, with attention to health literacy levels of the population, are needed if we are to improve state statistics and address health issues that are frequently associated with poverty in women and children.

    In Kentucky, like the remainder of the United States, most women deliver their newborns in hospitals and are discharged from the hospital 2-3 days after birth. In hospitals, most health education has traditionally consisted of providing verbal instruction and written health education materials before hospital discharge, but the efficacy and acceptability of these methods have not been comprehensively evaluated. In 2005, the Center for Medicare and Medicaid Services developed a standardized survey, the Hospital Consumer Assessment of Healthcare and Systems, to measure patients’ perspectives on the quality of hospital stays. The survey is administered by outside companies and includes questions about communication with nurses and discharge education.

    Key to effective patient education is tailoring materials and messages to appropriate literacy levels and preferred learning styles of patients [20,21], especially in families who are at risk for adverse outcomes due to low education and/or low literacy levels. Additionally important is teachers’ satisfaction with, and confidence in, using methods and materials when educating new mothers and families [22]. The purpose of this study was to determine the feasibility of 2 educational methods for teaching new mothers how to care for themselves and their infants after hospital discharge. Feasibility was measured by adequate enrollment, acceptability of the intervention to patients and nurses, and initial efficacy as described in a tutorial on pilot studies by Thabane et al [23].

    Review of the Literature

    Written educational materials are widely used at hospital discharge but may not be the most effective vehicle for educating today’s generation of new mothers [20,24,25]. Teaching that engages multiple senses has been shown to enhance learning [26,27]. For example, it has long been known that videotapes can portray real-life situations; employ actors, graphics, and words that are appropriate for a particular population; improve short-term knowledge [27]; and enhance retention of information better than written materials [28]. Research on dual coding theory has determined that when individuals both see and hear an explanation, they are able to generate more creative solutions to solve problems [26]. Dual coding theory assumes that there are 2 cognitive subsystems: one processes nonverbal events (imagery) and the other specializes in language. New technology that includes video and engages 2 cognitive subsystems provides an alternative, and potentially more effective, way to deliver health information [29].

    Increasingly, pregnant and parenting women are using technology to access health information [30]. In a recent US survey (Listening to Mothers III), nearly two thirds (64%) of pregnant or parenting women accessed online health information from a mobile phone in a typical week and 82% went on the Internet from a computer [31]. Women also reported using tablet devices (35%) and iPod Touch devices (21%) to access information on the Internet. Further testing is needed to determine which technology is most effective and acceptable. While some studies have shown that low-income individuals are less likely to access the Internet, it was concluded that decreasing literacy demands would increase accessibility and use of information [32,33].

    New mothers are often overwhelmed with the amount of new information that they are given at hospital discharge. In order to enhance learning, it may be more effective to focus on essential topics that new mothers must know about self and baby care before they visit a health care provider 2-4 days after hospital discharge [34,35]. One essential topic is knowledge of breastfeeding [36].

    Data from our maternity unit, the Center for Women and Infants at the University of Louisville Hospital (ULH), indicate there is room for improvement in our patient education. When asked whether nurses explained discharge information in a way that could be understood, 73.1% of mothers answered “Yes,” which was below the national average of 78% [37]. In addition, our earlier research indicated that some of our written health education for new mothers had a reading level that was too high [38] and that new mothers are comfortable using technology to obtain health information [39]. Thus, our nursing staff were motivated to develop and test an intervention to improve patient education, prompting this study.


    Methods

    Study Design

    During a specified period, all mothers on the Mother-Baby Unit were randomized to receive standard teaching or a newly developed teaching module as part of a quality improvement initiative, which included an evaluation component. Mothers were then asked if their data could be included in a research study. The study was approved by the site and the Institutional Review Board of the University.

    Sample

    Eligibility criteria included English-speaking mothers with live births, whose babies were not in the neonatal intensive care unit and were expected to be discharged with their birth mothers. Table 1 displays data related to demographics of the sample, for which there were no significant differences between the 2 groups (all P values >.05). A majority of the analytic sample were non-Hispanic white (n=39/98, 39.8%) or black (n=40/98, 40.8%) with a high school education (n=71/98, 72.4%) and a mean age of 26.2 years. All nurses on the Mother-Baby Unit who completed discharge teaching during the study period were asked to complete the nurse acceptability survey.

    Table 1. Overall baseline demographics and stratified by educational modality.
    View this table

    Intervention

    The study intervention was developed as follows. First, with guidance from the literature including the Baby Friendly Initiative [34-36], nursing staff and nursing leaders created a list of essential topics that new mothers must be taught before hospital discharge. Information was restricted to that needed by new mothers before their first pediatric office visit 2-3 days after discharge. Second, simple patient education brochures were developed on these topics, based upon national health literacy guidelines [40,41]. Third, the digital media services department of the university created short videos of the content and placed them on the YouTube channel. Fourth, nursing staff critiqued the pamphlets and videos. Minor revisions were made based upon this input. One hour of staff training was completed before initiation of the study. Finally, the YouTube channel was accessed through computer/tablets on the unit. Upon hospital discharge, new mothers were given information about how to access the YouTube channel if further clarification was needed.

    Study Measures

    Study measures included an investigator-created assessment of knowledge. Acceptability of the interventions was also measured in mothers and nurses.

    Procedures

    Using a table of random numbers, new mothers were randomized into the iPad or pamphlet conditions. After consenting to the study, mothers completed a pretest. After the intervention, they completed a post-test and acceptability survey. Nursing staff on the unit delivered the intervention. We examined the feasibility and acceptability of the 2 differing educational modalities in the new mothers by asking 9 questions, which are described in the “Results” section.

    Upon completion of the patient intervention, all nurses on the unit who participated in the new discharge teaching were asked to complete a brief survey to determine their level of acceptance regarding using YouTube videos and iPads to educate postpartum patients. The survey examined nurses’ perceived confidence and satisfaction in delivering the educational modalities through 5 questions, which are described in the “Results” section. The survey was distributed to nurses via email. Anonymous surveys were returned in an envelope to the unit and were picked up by the study team. A reminder email was sent twice before data collection was deemed complete.

    Power and Sample Size Justification

    For this study, all new mothers (live births) at ULH were considered. Based on our preliminary studies, we anticipated that 10% of all potential participants would not be eligible and/or willing to participate, and that 10% of the eligible/willing participants would be lost to follow-up. Therefore, we recruited 100 mothers (n=51 in the pamphlet group, and n=49 in the iPad group). This was a feasible sample size for the research team to recruit and enroll for the study. Two (2.0%) were lost to follow-up. All analyses were performed on data for the remaining 98 individuals (n=51 in the pamphlet group and n=47 in the iPad group). Power calculations were based on the anticipated total sample size (n=98) and were used for complete analysis. We developed separate mixed-effects general linear models for each of the outcomes. Based on the anticipated sample size, the study had 84% power to detect a 10% main effect of each treatment for each outcome. Therefore, the number of participants in each comparison group was more than sufficient.

    Statistical Analysis

    To determine the influence of the iPad versus simple pamphlet on knowledge of self-care and infant care, we started with straightforward tests for differences between the 2 groups of individuals. Independent samples t tests were used to test for differences among continuous variables, while chi-square Fischer exact tests and Wilcoxon methods (when appropriate) were used to test for differences among categorical variables. To examine outcome knowledge for self-care and infant care, separate mixed-effects general linear models were developed for each outcome. The educational modalities were analyzed as fixed effects, and time (week since randomization) was analyzed as a repeated measures effect. All main effects and two-way interaction effects were investigated for significance from the mixed-effects models that were developed. Data were collected from the YouTube channel to determine the frequency and duration of access after hospital discharge.


    Results

    Improvement in Outcomes Over Time

    As seen in Table 2, the iPad group had lower mean outcome scores at baseline (81.7% vs 84.3%, P=.27), but the difference in mean scores was not significant. By contrast, the iPad group had higher scores at follow-up (90.3% vs 88.7%, P=.43), but still did not reach significance. However, the improvement in scores was significantly higher for the iPad group (8.7% vs 4.4%, P=.02) compared to the pamphlet group.

    Table 2. Baseline scores, T2 scores, and change in scores over time stratified by group.
    View this table

    As seen in Table 3, taking a longitudinal approach, group (B=4.81, P=.36) and time (B=6.12, P<.001) significantly affected scores over time, while no significant interaction effect was observed (B=5.69, P=.09).

    Table 3. General linear model: scores by group, time, and group by time interaction.
    View this table

    Feasibility and Acceptability

    Mothers

    As seen in Table 4, new mothers found both the pamphlet and iPad to be feasible and acceptable modalities for receiving education about self-care and infant care. There were no significant differences in feasibility and acceptability responses between the 2 groups (all P values >.05).

    Table 4. Feasibility and acceptability measures for participants overall and stratified by group.
    View this table

    Nurses

    The nurses felt confident and satisfied using both the iPad and simple pamphlets, as seen in Table 5. The nurses had a mean age of 44.3 years (SD 13.9) and had, on average, 16.6 years of experience (SD 13.8).

    Table 5. Nurses’ confidence and satisfaction scores for administering the education modalities.
    View this table

    Follow-up Visits to YouTube

    Mothers who received the iPad intervention were provided information on how to return to the YouTube Channel to view the videos after hospital discharge; 8 of 45 mothers did so. The topics viewed after discharge were the following: breastfeeding (n=1), bottle feeding (n=1), and critical symptoms in mothers (n=6).


    Discussion

    Principal Findings

    The pamphlet and iPad were identified as feasible and acceptable modalities for educating new mothers about self-care and infant care. The nurses felt confident and satisfied administering both educational modalities.

    Limitations

    Limitations of the study include data collection from one organization, a cross-sectional design, and the use of investigator-developed questions. In addition, only English-speaking mothers and those with an infant being discharged home with them were included in the study. Our next study will address these limitations. In addition, the results may have been impacted by a ceiling effect, as both interventions were evaluated highly.

    Comparison With Prior Work

    In agreement with findings of other researchers [42], YouTube served as an effective method for sharing health information in this study. Further research should test the simultaneous use of written and creative video materials by health literacy level [43].

    Conclusions

    These findings provide a foundation to determine whether using the preferred teaching method from this study could improve long-term outcomes for women and their infants, and to examine the cost-effectiveness of delivering health information using technology. This study is in line with funding priorities of national organizations; both the Agency for Healthcare Research and Quality and Patient-Centered Outcomes Research Institute have set priorities to reduce health disparities for those most at risk, such as low-income women and children from inner cities. Results from this study hold great promise for improving the uptake of information among new mothers with limited literacy skills, their health status and that of their baby, and their satisfaction with care [33].

    Conflicts of Interest

    None declared.

    References

    1. World Health Organization. Standards for Maternal and Neonatal Care. 2006. Birth and Emergency Preparedness in Antenatal Care   URL: http:/​/www.​who.int/​reproductivehealth/​publications/​maternal_perinatal_health/​emergency_preparedness_antenatal_care.​pdf [accessed 2015-04-13] [WebCite Cache]
    2. Lori JR, Dahlem CHY, Ackah JV, Adanu RMK. Examining antenatal health literacy in Ghana. J Nurs Scholarsh 2014 Nov;46(6):432-440. [CrossRef] [Medline]
    3. U. S. Department of Health & Human Services. 2010. The Affordable Care Act, Section by Section   URL: http://www.hhs.gov/healthcare/rights/law/ [accessed 2015-04-13] [WebCite Cache]
    4. The Joint Commission. 2010. Advancing effective communication, cultural competence, and patient- and family-centered care: A roadmap for hospitals   URL: http://www.jointcommission.org/assets/1/6/aroadmapforhospitalsfinalversion727.pdf [accessed 2015-03-17] [WebCite Cache]
    5. Jiwa M, Long A, Shaw T, Pagey G, Halkett G, Pillai V, et al. The management of acute adverse effects of breast cancer treatment in general practice: a video-vignette study. J Med Internet Res 2014;16(9):e204 [FREE Full text] [CrossRef] [Medline]
    6. Montero-Marín J, Prado-Abril J, Botella C, Mayoral-Cleries F, Baños R, Herrera-Mercadal P, et al. Expectations among patients and health professionals regarding Web-based interventions for depression in primary care: a qualitative study. J Med Internet Res 2015;17(3):e67 [FREE Full text] [CrossRef] [Medline]
    7. Ong J, Miller PS, Appleby R, Allegretto R, Gawlinski A. Effect of a preoperative instructional digital video disc on patient knowledge and preparedness for engaging in postoperative care activities. Nurs Clin North Am 2009 Mar;44(1):103-15, xii. [CrossRef] [Medline]
    8. Legislative Research Commission. Frankfort, Kentucky: Task Force on Adult Eduction; 2000. Adult Education and Literacy in Kentucky, Research Report No. 296   URL: http://www.lrc.ky.gov/lrcpubs/rr296.pdf [accessed 2015-03-17] [WebCite Cache]
    9. U.S. Department of Health & Human Services, Administration for Children and Families. Child Maltreatment, 2011   URL: http://www.acf.hhs.gov/sites/default/files/cb/cm11.pdf [accessed 2015-03-17] [WebCite Cache]
    10. U.S. Department of Health & Human Services. Center for Head Injury Services. Rockville, MD Traumatic brain injury   URL: http://www.hhs.gov/asl/testify/2012/03/t20120319a.html [accessed 2015-03-17] [WebCite Cache]
    11. Every Child Matters Education Fund. Washington, DC We Can Do Better: Child Abuse and Neglect Deaths in America   URL: http://www.everychildmatters.org/storage/documents/pdf/reports/wcdbv2.pdf [accessed 2015-03-17] [WebCite Cache]
    12. Centers for Disease Control and Prevention. Breastfeeding Report Card - United States, 2012   URL: http://www.cdc.gov/breastfeeding/pdf/2012breastfeedingreportcard.pdf [accessed 2015-03-17] [WebCite Cache]
    13. Bailey R, Blackmon H, Stevens F. Major depressive disorder in the African American population: Meeting the challenges of stigma, misdiagnosis, and treatment disparities. J Natl Med Assoc 2009;101(11):1084-1089.
    14. Bellis M, Lowey H, Leckenby N, Hughes K, Harrison D. Adverse childhood experiences: Retrospective study to determine their impact on adult health behaviours and health outcomes in a UK population. J Publ Health 2014;36(1):81-91.
    15. Belsky J, Bell B, Bradley RH, Stallard N, Stewart-Brown SL. Socioeconomic risk, parenting during the preschool years and child health age 6 years. Eur J Public Health 2007 Oct;17(5):508-513 [FREE Full text] [CrossRef] [Medline]
    16. Bornstein M, Bradley R. Socioeconomic Status, Parenting, and Child Development. Mahwah, NJ: Erlbaum; 2003.
    17. Bradley RH, Corwyn RF. Socioeconomic status and child development. Annu Rev Psychol 2002;53:371-399. [CrossRef] [Medline]
    18. Duncan GJ, Ziol-Guest KM, Kalil A. Early-childhood poverty and adult attainment, behavior, and health. Child Dev 2010;81(1):306-325. [CrossRef] [Medline]
    19. Ertel K, Rich-Edwards J, Koenen K. Maternal depression in the United States: Nationally representative rates and risks. J Womens Health 2011;20(11):1609-1617.
    20. Giuse NB, Koonce TY, Storrow AB, Kusnoor SV, Ye F. Using health literacy and learning style preferences to optimize the delivery of health information. J Health Commun 2012;17 Suppl 3:122-140. [CrossRef] [Medline]
    21. Stanczyk N, Bolman C, van Adrichem M, Candel M, Muris J, de Vries H. Comparison of text and video computer-tailored interventions for smoking cessation: randomized controlled trial. J Med Internet Res 2014;16(3):e69 [FREE Full text] [CrossRef] [Medline]
    22. Lin CA, Neafsey PJ, Anderson E. Advanced practice registered nurse usability testing of a tailored computer-mediated health communication program. Comput Inform Nurs 2010;28(1):32-41 [FREE Full text] [CrossRef] [Medline]
    23. Thabane L, Ma J, Chu R, Cheng J, Ismaila A, Rios LP, et al. A tutorial on pilot studies: the what, why and how. BMC Med Res Methodol 2010;10:1 [FREE Full text] [CrossRef] [Medline]
    24. Gentles S, Lokker C, McKibbon K. Health information technology to facilitate communication involving health care providers, caregivers, and pediatric patients: a scoping review. J Med Internet Res 2010;12(2):e22 [FREE Full text] [CrossRef] [Medline]
    25. Wilson EA, Makoul G, Bojarski EA, Bailey SC, Waite KR, Rapp DN, et al. Comparative analysis of print and multimedia health materials: a review of the literature. Patient Educ Couns 2012 Oct;89(1):7-14. [CrossRef] [Medline]
    26. Clark JM, Paivio A. Dual coding theory and education. Educ Psychol Rev 1991 Sep;3(3):149-210. [CrossRef]
    27. Meade CD, McKinney WP, Barnas GP. Educating patients with limited literacy skills: the effectiveness of printed and videotaped materials about colon cancer. Am J Public Health 1994 Jan;84(1):119-121. [Medline]
    28. Browner CH, Preloran M, Press NA. The effects of ethnicity, education and an informational video on pregnant women's knowledge and decisions about a prenatal diagnostic screening test. Patient Educ Couns 1996 Mar;27(2):135-146. [Medline]
    29. Chi DL, Pickrell JE, Riedy CA. Student learning outcomes associated with video vs. paper cases in a public health dentistry course. J Dent Educ 2014 Jan;78(1):24-30 [FREE Full text] [Medline]
    30. Lewallen LP, Côté-Arsenault DY. Implications for nurses and researchers of Internet use by childbearing women. Nurs Womens Health 2014;18(5):392-400. [CrossRef] [Medline]
    31. Declercq E, Sakala C, Corry M, Applebaum S, Herrlich A. New York: Childbirth Connection. 2013. Listening to mothers III: new mothers speak out   URL: http://transform.childbirthconnection.org/reports/listeningtomothers/ [accessed 2015-03-17] [WebCite Cache]
    32. Jensen JD, King AJ, Davis LA, Guntzviller LM. Utilization of internet technology by low-income adults: the role of health literacy, health numeracy, and computer assistance. J Aging Health 2010 Sep;22(6):804-826. [CrossRef] [Medline]
    33. Zarghom S, Di Fonzo D, Leung F. Does socioeconomic status affect patients' ease of use of a touch-screen (iPad) patient survey? Interact J Med Res 2013;2(1):e1 [FREE Full text] [CrossRef] [Medline]
    34. Wade SL, Oberjohn K, Burkhardt A, Greenberg I. Feasibility and preliminary efficacy of a web-based parenting skills program for young children with traumatic brain injury. J Head Trauma Rehabil 2009;24(4):239-247. [CrossRef] [Medline]
    35. Vandelanotte C, Duncan M, Plotnikoff R, Mummery W. Do participants' preferences for mode of delivery (text, video, or both) influence the effectiveness of a Web-based physical activity intervention? J Med Internet Res 2012;14(1):e37 [FREE Full text] [CrossRef] [Medline]
    36. World Health Organization, UNICEF. Baby-friendly hospital initiative, 2009   URL: http://www.who.int/nutrition/topics/bfhi/en/ [accessed 2015-03-17] [WebCite Cache]
    37. HCAHPS Hospital Survey, 2015. Baltimore, MD: Centers for Medicare & Medicaid Services   URL: http://www.hcahpsonline.org/files/August_2013_HCAHPS_Fact_Sheet3.pdf [accessed 2015-03-26] [WebCite Cache]
    38. Ryan L, Logsdon M, McGill S, Stikes R, Senior B, Helinger B, et al. Evaluation of printed health education materials for use by low education families. J Nursing Scholarsh 2014;46(4):212-228.
    39. Logsdon MC, Bennett G, Crutzen R, Martin L, Eckert D, Robertson A, et al. Preferred health resources and use of social media to obtain health and depression information by adolescent mothers. J Child Adolesc Psychiatr Nurs 2014 Nov;27(4):163-168. [CrossRef] [Medline]
    40. AHRQ Health Literacy Universal Precautions Toolkit 2nd edition. Rockville, MD: Agency for Healthcare Research Quality; 2015.   URL: http:/​/www.​ahrq.gov/​professionals/​quality-patient-safety/​quality-resources/​tools/​literacy-toolkit/​index.​html [accessed 2015-04-13] [WebCite Cache]
    41. Doak C, Doak L, Root J. Teaching patients with low literacy skills. Philadelphia: J.B. Lippincott; 1996.
    42. Knight E, Intzandt B, MacDougall A, Saunders T. Information seeking in social media: A review of YouTube for sedentary behavior content. Interact J Med Res 2015;4(1):e3.
    43. Meppelink CS, van Weert JCM, Haven CJ, Smit EG. The effectiveness of health animations in audiences with different health literacy levels: an experimental study. J Med Internet Res 2015;17(1):e11 [FREE Full text] [CrossRef] [Medline]


    Abbreviations

    ULH: University of Louisville Hospital


    Edited by G Eysenbach; submitted 27.04.15; peer-reviewed by S Bailey, J Gregg; comments to author 22.07.15; revised version received 11.08.15; accepted 15.08.15; published 08.10.15

    ©M Cynthia Logsdon, Deborah Davis, Diane Eckert, Frances Smith, Reetta Stikes, Jeff Rushton, John Myers, Joshua Capps, Kathryn Sparks. Originally published in the Interactive Journal of Medical Research (http://www.i-jmr.org/), 08.10.2015.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Interactive Journal of Medical Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.i-jmr.org/, as well as this copyright and license information must be included.