The Role of Health Literacy in Developing Emergency Department Discharge Instruction for Patient with Mild Traumatic Brain Injury

Abstract

Mild traumatic brain injury (mTBI) is the most common type of traumatic brain injury (TBI) that is seen in emergency departments (ED) representing up to 90% of all TBIs. The growing burden following mTBI highlights the importance of early education and reassurance for ED patients following mTBI. However, poor understanding and recall of mTBI discharge instructions are often reported in the literature which highlight a great concern for the quality and reliability of these instructions. Hence, this study aimed to determine the role of health literacy in developing a new set of ED written discharge instruction for patients with mTBI. This study is divided into three phases. Phase 1 was the needs assessment of mTBI written discharge instructions made available from government hospitals of Ministry of Health (MOH) around the country. All 132 EDs of the government hospitals in Malaysia were contacted and requested to send a copy of the written discharge instruction that they give to their mTBI patients. These instructions were evaluated using the Patient Education Materials Assessment- Printable Tool (PEMAT-P) for understandability and actionability. Readability was measured using an online readability tool of Malay text. The content was compared against the discharge instructions recommended by established clinical practice guidelines. Phase 2 was the needs assessment of 62 recently discharged patients who had received mTBI written discharge instructions at one particular ED who were evaluated using the Malaysian version of the Health Literacy Skill Instrument (M- HLSI) and Montreal Cognitive Assessment (MoCA). Prior to the evaluation, cross- cultural validation of the M-HLSI, an adaptation of the short form version of HLSI (HLSI-SF) in English, was conducted among 319 Malay speakers and also in a sample of patient with mTBI that would not be participants of the main study. Phase 3 was developing a set of new mTBI written discharge instruction based on the findings of the needs assessment and previous results found in the literature. The findings from Phase 1 found 49 printed discharge instructions eligible for the study: 26 of the articles met the criteria of understandability, but only 3 met the criteria for actionability. The average readability level met the reading ability of the average adult in Malaysia. However, most of the discharge instructions focused on emergency symptoms, but none contained post- concussion features for reassurance. In Phase 2, the M-HLSI was found to be a reliable and valid instrument, according to Rasch model analysis. The study finding revealed the high prevalence of limited health literacy among participants, particularly in the mTBI group (54.8%). The needs assessment of the participants showed their health literacy level was associated with gender (p=0.022) and education attainment (p=0.011). mTBI participants in both health literacy groups (limited and sufficient) performed better in print literacy and oral literacy skill compared to numeracy skill and information-seeking skill. As for cognitive function, there were significant differences in executive functioning, attention, concentration, language, memory and orientation between patients that were mildly cognitive deficit and those with no cognitive deficit. In Phase 3, there was a significant improvement in percentage scores of understandability (97.4% to 97.8%) and actionability (49.8% to 99.1%) and readability of the newly-developed mTBI discharge instructions compared to those reviewed in Phase 1. Ultimately, this understandable, actionable and readable written discharge instruction may facilitate the ED health care providers in communicating the discharge instructions effectively and may serve as a useful guide for patient self-management regardless of their health literacy level.