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Use of a Low-Literacy Patient Education Tool to Enhance Pneumococcal Vaccination Rates
A Randomized Controlled Trial
Terry A. Jacobson, MD;
Donna M. Thomas, MPH;
Felicia James Morton, MSPH;
Gardiner Offutt, RN, MPH;
Jennifer Shevlin, MSPH;
Susan Ray, MD
JAMA. 1999;282:646-650.
Context Pneumococcal immunization rates for elderly and high-risk patients are only one third to one half the target rate of 60% established by the US Public Health Service. Limited or marginal literacy, which affects nearly 100 million Americans, especially the elderly, may contribute to these low rates of immunization.
Objective To determine whether the use of a simple, low-literacy educational tool enhances patient-physician dialogue about pneumococcal vaccination and increases rates of immunization.
Design A randomized controlled trial conducted between May and June of 1998.
Setting Ambulatory care clinic of a 900-bed public teaching hospital serving a predominantly indigent, low-literate, African American, inner-city population.
Participants Of 433 patients who presented for routine primary care, had vaccine indications (age  65 years or chronic disease), and had not been previously vaccinated, 221 were randomly assigned to the intervention group and 212 to the control group. Of the total patient population (mean age, 63 years), 280 (64.7%) had less than a high school education, 401 (92.6%) were African American, and 300 (69.3%) were female.
Intervention One-page, low-literacy (below fifth-grade level) educational handout encouraging patients to "ask your doctor about the pneumonia shot" vs a control group (1-page, low-literacy educational handout conveying information about nutrition).
Main Outcome Measures Vaccination rates (documented by chart audit) of patients who received pneumococcal vaccination and rates of patients who self-reported having discussed vaccination with their physicians.
Results Patients in the intervention group were 4 times more likely to have discussed the pneumococcal vaccine with their physicians than patients in the control group (87/221 [39.4%] vs 21/212 [9.9%]; relative risk [RR], 3.97 [95% confidence interval {CI}, 2.71-5.83]), and were more than 5 times as likely to have received the pneumococcal vaccine than the control group (44/221 [19.9%] vs 8/212 [3.8%]; RR, 5.28 [95% CI, 2.80-9.93]). In a multivariate analysis controlling for race, sex, education, insurance status, age, level of physician training, health status, and vaccine indication, only assignment to the intervention group was statistically significantly related to the probability of being immunized or discussing the issue with their physicians (P<.001 for both trends).
Conclusions A simple, low-literacy educational tool increased pneumococcal vaccination rates and patient-physician discussions about the vaccine in an elderly, low-literate, indigent, minority population.
Author Affiliations: Department of Medicine, Emory University School of Medicine (Drs Jacobson and Ray and Ms Thomas), The Office of Health Promotion and Disease Prevention, Grady Health System (Dr Jacobson and Ms Morton), The Atlanta Veterans Affairs Medical Center (Mss Offutt and Shevlin), and the Georgia Emerging Infections Program (Mss Thomas, Offutt, and Shevlin and Dr Ray), Atlanta, Ga.
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