Abstract
Limited patient understanding of hypertension contributes to poor health outcomes. In 2 sequential randomized studies, the authors determined the impact of administering information tailored to health literacy level alone or in combination with preferred learning style on patients' understanding of hypertension. Patients with high blood pressure were recruited in an academic emergency department. In Experiment 1 (N = 85), the control group received only the routine discharge instructions; the intervention group received discharge instructions combined with information consistent with their health literacy level as determined by the Short Test of Functional Health Literacy. In Experiment 2 (N = 87), the information provided to the intervention group was tailored to both health literacy and learning style, as indicated by the VARK™ Questionnaire. To measure learning, the authors compared scores on a hypertension assessment administered during the emergency department visit and 2 weeks after discharge. Participants who received materials tailored to both health literacy level and learning style preference showed greater gains in knowledge than did those receiving information customized for health literacy level only. This study demonstrates that personalizing health information to learning style preferences and literacy level improves patient understanding of hypertension.
[Supplementary materials are available for this article. Go to the publisher's online edition of Journal of Health Communication for the following free supplemental resources: Appendix A: High Blood Pressure Questionnaire; and Appendix B: Multivariate linear regression of adjusted association between intervention and knowledge retention (with item 17 included). Appendix A is the hypertension knowledge test developed and previously described (Koonce, Giuse, Alexander, & Storrow, Citation2011). Appendix B provides the results of the multivariate linear regression analysis of the data set with the inclusion of all 17 quiz items.]
To self-manage hypertension, patients must be able to understand and follow basic instructions regarding their care. For nearly half of all adults living in the United States, comprehending and acting upon health information poses a challenge (Nielson-Bohlman, Panzer, & Kindig, Citation2004). Health literacy is defined as the ability “to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (Selden, Zorn, Ratzan, & Parker, Citation2000). Low health literacy levels correlate with decreased treatment regimen compliance and increased mortality (Desmedt & Vackle, Citation2004).
Nearly 31% of Americans 20 years of age and older have hypertension, and disease incidence increases with age (Centers for Disease Control and Prevention, 2011). Particularly vulnerable populations include African Americans and impoverished individuals, groups also associated with higher prevalence of inadequate health literacy (Centers for Disease Control and Prevention, 2009). Hypertension is frequently called “the silent killer” because patients are often asymptomatic and unaware they have it (an estimated 25% of hypertensive patients), and of those knowing they have the disease, only 65% receive treatment (Centers for Disease Control and Prevention. National Center for Health Statistics, 2009).
Patients with low health literacy are more likely to seek treatment from critical care facilities and less likely to receive preventative screenings (McCray, Citation2005). Effective communication with such patients presents a challenge in the emergency department, where patient–provider time is limited; an estimated 78% of patients report difficulty comprehending information presented to them during their emergency department visit (Clarke et al., Citation2005; Engel et al., Citation2009; Spandorfer, Karras, Hughes, & Caputo, Citation1995).
The literature shows that personalized patient education often results in better outcomes than a generic approach; yet, few studies consider the influence of the mode of knowledge (Inott & Kennedy, Citation2011; Kandula et al., Citation2009). People vary in their preferences for orally delivered, written, or illustrated materials; for some, the optimal method is by doing (termed kinesthetic learners). To facilitate hypertension understanding, we studied individual emergency department patients' learning preferences and provided them with information accordingly. Using a randomized controlled study design, we investigated whether appealing to health literacy level alone or in conjunction with preferred learning style enhances educational outcomes in emergency department patients with high blood pressure.
Method
The Vanderbilt University Medical Center Institutional Review Board approved this protocol.
Study Design
We evaluated two strategies for optimizing the delivery of health information; key elements of the study design are depicted in Figure . First, we examined whether customizing educational material to patients' health literacy level affected their retention of hypertension information (Experiment 1). We initially determined patients' health literacy level using the Short Test of Functional Health Literacy (S-TOFHLA; Baker, Williams, Parker, Gazmararian, & Nurss, 1999). To measure changes in learning, we compared performance on a hypertension knowledge test before and after intervention.
Figure 1 Study design schematic. Health literacy levels are reflective of categories ascertained by the Short Test of Functional Health Literacy (S-TOFHLA; Baker et al., Citation1999). The selection of the learning style preferences are based on the VARK™ (Fleming & Mills, Citation1992).
In a separate patient cohort (Experiment 2), we examined whether customizing information to health literacy level and learning style resulted in enhanced retention of hypertension knowledge. We assessed learning style preferences using the Visual, Aural, Read/Write, Kinesthetic (VARK™) Inventory (Fleming & Mills, Citation1992). The overall research design paralleled that of Experiment 1.
Participants
We recruited patients in the emergency department at Vanderbilt University Medical Center. To be eligible, participants had to be 18 years of age or older and have at least two blood pressure measurements of 140/90 mmHg or higher while in the emergency department (Chobanian et al., Citation2003). Exclusion criteria included the presence of any of the following: cognitive impairment, psychiatric chief complaint, or an Emergency Severity Index of 1 (Tanabe, Gimbel, Yarnold, & Adams, Citation2004). We collected information from participants regarding age, gender, race/ethnicity, education, employment status, personal and family history of hypertension, use of hypertension medications, smoking status, chief complaint for the emergency department visit, and Visual Analog Scale pain score using data from the electronic medical record system (Giuse, Citation2003) in combination with print forms.
From February 14, 2011, through March 7, 2011, we enrolled patients in Experiment 1, assessing the effects of information customized to health literacy level on retention of hypertension information. We included patients that spoke English or Spanish and identified 190 patients for potential study inclusion. After exclusions, 93 were randomized in a 1:1 ratio to control or intervention groups using a permuted block design with random block sizes of 2, 4, and 6. We were unable to contact 3 control and 5 intervention group participants for the follow-up phone call, resulting in 85 patients (45 control and 40 intervention) completing the study (Figure ). Of the 8 patients lost to follow-up, 5 had disconnected phone numbers, 2 provided incorrect numbers, and 1 never answered.
Figure 2 Patient flowchart for Experiment 1.
We next examined the effects of customizing information to health literacy and learning style using a separate patient cohort (Experiment 2). Participants were recruited from May 17, 2011, through June 20, 2011. We included only English speaking patients because of the low number of Spanish-speaking patients in Experiment 1 (see Table ). In Experiment 2, we also collected information regarding subjects' annual household income. We identified 216 patients for potential study inclusion; after exclusions, 103 patients were randomized to control or intervention groups. We randomized subjects using the permuted block design described earlier. In this study cohort we additionally stratified the randomization by level of education. We were unable to follow up with 8 control and 8 intervention group participants, resulting in 87 patients (41 control and 46 intervention) completing the study (Figure ). Of the 16 patients lost to follow-up, 2 had disconnected phone numbers; 1 provided an incorrect number, 5 were too ill to complete the questionnaire, 1 withdrew from the study, and 7 never answered.
Figure 3 Patient flowchart for Experiment 2.
Table 1. Patient characteristics
Measures
The hypertension knowledge test, which we developed and previously described (Koonce, Giuse, Alexander, & Storrow, Citation2011), consisted of 17 items and included multiple choice and true/false questions. Questions addressed various facets of hypertension, including its definition, symptoms, causes, risk factors, and treatment. The quiz represented a key component of the study design and was necessary for measuring baseline hypertension knowledge before intervention.
In Experiment 1, we measured health literacy using the reading comprehension portion of the S-TOFHLA, which consists of 36 items. The test groups subjects into one of three health literacy categories based on their number of correct responses: inadequate (0–16), marginal (17–22) and adequate (23–36).
We also investigated the feasibility of using the shorter health literacy assessment described by Chew, Bradley, and Boyko (Citation2004). Patients were asked to rate their confidence in filling out medical forms, the frequency for which they need help reading hospital materials, and how often they experienced problems learning about medical conditions due to reading comprehension difficulties. The test is scored on a 12-point scale with a low score denoting high health literacy. We classified health literacy level based on scores as follows: adequate (0–4), marginal (5–6), and inadequate (7–12).
The Chew and colleagues (Citation2004) health literacy questions were previously shown to identify low health literacy patients equally well as the S-TOFHLA (Chew et al., Citation2008; McNaughton, Wallston, Rothman, Marcovitz, & Storrow, 2011). A similar significant correlation between the two assessments (Spearman's correlation coefficient = –0.46; p<.001) was also observed by our team. In addition, we found that the questions in Chew and colleagues (Citation2004) took approximately 2 minutes to complete, whereas the S-TOFHLA requires 7 minutes. Because of time constraints, we did not administer the S-TOFHLA, and instead used the Chew and colleagues (Citation2004) questionnaire to determine health literacy level in Experiment 2.
We examined learning preferences using the VARK™, a 16-item, scenario-based, multiple choice assessment that takes approximately 10 minutes to complete (Fleming & Mills, Citation1992). The VARK™ categorizes subjects as having a preference for a single or multiple modalities (visual, aural, read/write, or kinesthetic) based on test scores.
Intervention
All subjects received standard of care discharge instructions (printed information on the basis of the patient's chief complaint); however, only those in the intervention groups were given personalized hypertension materials.
We developed core and supplemental versions of the personalized materials, written at the fifth- and eighth-grade reading level, respectively. The core set contained the minimal information needed to correctly answer the hypertension knowledge test. The supplemental version elaborated upon concepts included in the core material.
The materials were administered using a tiered framework, which was modeled after the approach used by Wolff and colleagues (Citation2009). In Experiments 1 and 2, intervention group participants with either inadequate or marginal health literacy received the core set. Those with marginal health literacy were also given the option of receiving the supplemental set. Adequate health literacy patients received both versions (Koonce et al., Citation2011).
In Experiment 2, we also adapted a core and supplemental version of the materials according to the four learning modalities. Visual learners received handouts illustrated with pictures and charts. Patients with a preference for learning via read/write techniques received materials designed to maximize the effect of the written word (e.g., bullet points, lists). Aural learners listened to an audio version of the health information during their emergency department visit. For later review after the emergency department visit, aural learners were also provided a compact disc and local telephone number to call; both contained the audio recording. Kinesthetic learners were given a card-sorting activity to complete in the emergency department and at home. Patients with multimodal learning preferences received information in all formats matching their learning style preferences.
Follow-Up Assessment
We readministered the high blood pressure knowledge test by telephone approximately 2 weeks after the patients were discharged. Participants were also asked to rate their agreement on a 5-point Likert scale ranging from 1 (strong disagreement) to 5 (strong agreement) with statements addressing their satisfaction with the provided materials and whether they looked up hypertension information on their own. Those who completed the follow-up interview received a $15 gift card to a local grocery store.
Statistical Analysis
To assess learning, we initially compared changes in the primary outcome of mean number of questions answered correctly on the hypertension knowledge quiz before and after intervention using paired t tests. An earlier pilot study (Koonce et al., Citation2011) indicated that the high blood pressure quiz had a standard deviation of 2.36. With a sample size of 74, the studies provide at least 95% power to detect a difference of two correctly answered questions on the hypertension knowledge quiz before and after intervention at a two-sided 5% significance level.
We next used multivariate linear regression analyses to determine the contribution of specific factors to the test scores while adjusting for other covariates in the model. In Experiment 1, a backward model selection procedure was performed, resulting in a multivariate regression model containing the following variables: S-TOFHLA score, past history of high blood pressure, posttest administrator, and treatment–administrator interaction. In Experiment 2, we adjusted the analysis for gender, race, pain score, highest level of education, household income, follow-up interviewer, and treatment–interviewer interaction. Our primary data analysis for both studies included outcomes from questions 1 to 16 of the postintervention high blood pressure quiz. We omitted item 17 from the primary analysis because the educational materials the patients were provided did not contain all the information needed to correctly answer the question.
In Experiment 1, 2 patients answered “this year,” rather than giving a number, when asked how many years had passed since they were diagnosed with hypertension. We estimated their time since diagnosis using a uniform distribution (0, 3/12) because the survey was completed in March. In the Experiment 2 data set there were 7 missing values (8%) for household income. In both studies, the multiple imputation method was used to estimate the missing values. The estimates from the 100 iterations were then averaged to produce a single combined value, along with an estimated pooled variance (Rubin, Citation1987).
Hypotheses were tested at the .05 significance level. All study data was entered in REDCap, a secure, web-based research database (Harris et al., Citation2009). Analyses were performed in R 2.13.0 by a statistician blind to the treatment assignment.
Results
Study Participants
A total of 196 individuals participated in both studies. Of these subjects, 83.7% (164/196) had adequate health literacy, 8.7% (17/196) had marginal, and 7.7% (15/196) had inadequate health literacy. Of patients participating in Experiment 2, nearly half (51/103) showed a strong preference for a single learning modality and the remainder held multimodal preferences.
Patients were similarly distributed across control and treatment groups by age, gender, race, Emergency Severity Index, employment status, mean number of years with high blood pressure, use of high blood pressure medications, health literacy level, and learning style preferences (Table ). Intervention group participants had slightly higher pain scores in both studies. In Experiment 1, a higher percentage of patients in the intervention group reported receiving an education beyond the high school level than controls (71% vs. 54%).
Hypertension Knowledge Differences
The percentage of patients with correct answers on the hypertension knowledge test varied by question (Table ). In both studies, there was variability in the control participants' performance on individual items on the posttest relative to their pretest scores. By contrast, intervention group participants consistently performed better on individual items on the posttest across both studies. In Experiment 1, the percentage change ranged from 2% to 45%, and in the second study, it ranged from 4% to 60% for individual test items. Intervention group participants of Experiment 2 showed greater improvements on all but two items, compared with those of Experiment 1. Excluding item 17, for 7 of the items in Experiment 1 and 12 in Experiment 2, the increase in percentage of intervention group participants responding correctly on the posttest relative to their pretest values was greater than or equal to 25%.
Table 2. Percentage of patients responding correctly to individual hypertension knowledge test items
We did not observe a significant difference in pre- and posttest scores of control subjects in both studies (Figure ). In Experiment 1, intervention group subjects answered more questions correctly on the posttest than on the pretest (Δ = 4.0 questions; p<.001). Intervention group subjects of Experiment 2, who received materials customized to both health literacy level and learning style preference, showed even greater improvements in posttest scores relative to pretest values (Δ = 6.3 questions; p<.001).
Figure 4 Absolute change in the number of correct responses on the hypertension quiz; paired t test p<.0001 in both studies.
In Experiment 1, a multivariate regression analysis revealed the following significant predictors of the hypertension posttest score: hypertension pretest score, assignment to intervention group, number of years with hypertension, and follow-up interviewer. In Experiment 2, the following significant predictors of the hypertension posttest score were identified: hypertension pretest score, assignment to intervention group and follow-up interviewer. In both experiments, a significant interaction was also observed between the posttest scores of patients in the intervention groups and the posttest interviewer (Table ). A multivariate linear regression analysis of the data set with the inclusion of all 17 quiz items revealed the same set of significant predictors.
Table 3. Multivariate linear regression of adjusted association between intervention and knowledge retention
High Blood Pressure Information Seeking
In Experiment 1, 18% (8/44) of control and 23% (9/39) of intervention group subjects agreed or strongly agreed to the statement, “Since the visit to the emergency room I have looked up information about high blood pressure on my own.” In Experiment 2, 24% (10/41) of control and 14% (6/44) of intervention participants reported that they agreed/strongly agreed to this statement.
Discussion
In our study, we chose to assess health literacy and learning preferences, as the combination of the two may provide a more powerful mechanism to enhance learning than either alone. The intersection of both elements used in tandem for the delivery of individualized health information is depicted by the matrix architecture shown in Figure .
Figure 5 Optimizing the delivery of health information. (Color figure available online.).
This study is one of the first of its size to demonstrate that combining both elements improves recall for health information. We observed that intervention group participants answered many more questions correctly on the hypertension knowledge posttest than control subjects, who showed no significant change in test results. Posttest performance and learning were even greater in patients who received materials matched to both their literacy level and learning preference than those who received information customized to health literacy alone.
Health literacy is measured using numerous validated and well-described assessment instruments. We compared health literacy scores determined by the S-TOFHLA and the Chew and colleagues (Citation2004) questions and found a correlation between the two assessments, as described previously (Chew et al., Citation2008; McNaughton et al., Citation2011). We found the Chew and colleagues (Citation2004) questions were easier and faster to administer than the S-TOFHLA and were therefore better suited for the workflow of a fast-paced clinical setting.
In our study population, 50% (51/103) of patients participating in Experiment 2 displayed a strong preference for a single learning modality as determined by the VARK™ inventory; the remainder held multimodal preferences. This finding is consistent with educational research studies examining optimal learning techniques (Breckler, Joun, & Ngo, Citation2009; Fleming & Mills, Citation1992; Murphy, Gray, Straja, & Bogert, Citation2004). Although there is some controversy over whether teaching according to learning style improves retention (Pashler, McDaniel, Rohrer, & Bjork, Citation2009), the failure of interventions targeting only learning preferences may in part be due to other variables, including overall memory function, anxiety, motivation, and complexity of the material (Kessels, Citation2003). Furthermore, learning preferences are thought to be dynamic and may change for a specific individual with experience and time (Fleming & Mills, Citation1992; Mainemelis, Boyatzis, & Kolb, Citation2002; Truluck & Courtenay, Citation1999).
A surprising finding was an interaction between patient performance on the hypertension knowledge test and the study interviewer. The interviewer–test score interaction may reflect motivational factors that we were unable to control despite an established protocol for patient interactions. The interviewer associated with increased hypertension knowledge test scores held more than 30 years as an educator and customer service provider. Feedback from study participants suggests she established a strong rapport with several patients; her unique skills and personality may have motivated participants to engage more fully in the hypertension knowledge posttest.
In both studies, we provided patients with marginal health literacy the option of receiving the supplemental educational materials in addition to the core set. All participants in this group chose to receive the supplemental versions, thus suggesting a strong desire to learn more about their health condition.
In our study, we were unable to reach 7 patients due to disconnected telephone numbers. The use of mobile technologies to facilitate health communication practices has recently garnered much attention (Fortney, Burgess, Bosworth, Booth, & Kaboli, 2011; Tirado, Citation2011). A reliance on mobile devices may disadvantage low-income individuals who do not have stable access. Our findings indicate a potential need to pay close attention to this issue in future research.
The results of Experiment 1 revealed the number of years since hypertension diagnosis to be a significant predictor of posttest scores. This finding was not observed in Experiment 2, suggesting that adapting material to both health literacy and learning style may help overcome knowledge gaps among those who have had high blood pressure for a shorter time period. This highlights the importance of considering both health literacy level and learning style preference, rather than just health experience, when providing educational materials.
The Institute of Medicine's seminal report, Crossing the Quality Chasm, identified the need for the health care industry to be “respectful of and responsive to individual patient preferences, needs, and values” (Committee on Quality of Health Care in America, Institute of Medicine, 2001). More recently, the Institute of Medicine identified several common themes for patient-anchored care, including the importance of engaging patients in their own care for better health outcomes and personalizing treatments according to individual patient circumstances and preferences (Institute of Medicine, 2011). The proliferation of consumers seeking health information online, combined with the move toward patient-centered care, contributes to rapid changes to the traditional doctor–patient relationship (Stevenson, Kerr, Murray, & Nazareth, Citation2007; Wald, Dube, & Anthony, Citation2007). Informed patients can “share the burden of responsibility for knowledge” that may lead to more efficient use of time during a clinical encounter, and possibly improved health outcomes (Bylund et al., Citation2007; Wald et al., Citation2007).
Over the past decade, efforts to improve patient-centered care focused heavily on health literacy. Multiple studies indicate limited health literacy negatively affects health knowledge, behavior and outcomes, with less literate patients experiencing increased medication errors, longer hospital stays, and increased mortality (Dewalt, Berkman, Sheridan, Lohr, & Pignone, 2004; McCray, Citation2005). Health literacy, while important, represents only one element of comprehension and understanding; learning style preferences also play a key role. The education, psychology, and cognitive learning literature widely reflects the use of many different learning style assessments to evaluate individual preferences (Desmedt & Valcke, Citation2004; James & Blank, Citation1993) and how they can be used for personalized instruction. Although used extensively in general educational and biomedical research to measure student learning preferences, tools designed to assess learning styles have received little attention in clinical settings to inform health communication (Carbone, Lennon, Torres, & Rosal, Citation2005; Dinakar, Adams, Brimer, & Silva, Citation2005). Several investigators describe the need to assess learning styles for patient education, yet few implemented interventions that adapt material to specific learning modality preferences (Beagley, Citation2011; Cavanagh & Coffin, 2004; Inott & Kennedy, Citation2011).
Our results are especially encouraging given the challenging, fast-paced environment of the emergency department where clinical care is focused on acute needs. Hypertension, a major risk factor for acute and chronic diseases including ischemic heart disease, end stage renal disease, and stroke, has far-reaching public health implications (Centers for Disease Control and Prevention, 2011). Engel and colleagues (Citation2009) found that nearly 78% of patients do not remember health information provided during the emergency department visit. Zavala and Shaffer (Citation2011) reported nearly one third of patients had questions or were confused about their self-care instructions in follow-up phone calls made the day after discharge from the emergency department. Furthermore, studies over the past three decades have shown a discrepancy between the reading levels of health-related materials and their intended audience (Nielsen-Bohlman et al., 2004). Our study provided an opportunity to potentially reduce the uncertainty that results from generalized communication approaches not matched to an individual's personal characteristics.
Limitations
Although the emergency department at the Vanderbilt University Medical Center provided an environment to investigate the effect of the intervention on learning outcomes in a complex and dynamic setting, 84% (164/196) of the participants had adequate health literacy. The reported percentage of adequate health literacy was consistent with that observed in settings with comparable patient populations (Matsuyama et al., Citation2011; McNaughton et al., Citation2011). Our study was not powered to compare changes in learning across different literacy levels. The next phase of our research includes a collaboration with a local health clinic that provides care for a medically underserved and socioeconomically diverse community. The partnership will enable us to better understand the effect of limited health literacy and its association with learning preferences for the retention of health information.
Additionally, we did not record the follow-up phone calls and therefore were unable to objectively evaluate differences in each study interviewer–patient encounter. Studies indicate that test-takers work harder to produce reliable and valid information when they trust the administrator (Strauss & Corbin, Citation1997; Worthen, Borg, & White, Citation1993); our study interviewers may have differed with respect to the degree to which they established a rapport with patients. In future studies, we plan to qualitatively analyze the return calls to better characterize the effect of the test administrator on the patients' performance.
Conclusion and Implications
Patients must fully understand the health information that is presented to them to be true partners in their care (Kessels, Citation2003; Watson & McKinstry, Citation2009); multiple studies indicate that engaged patients have better health outcomes (Scalise, Citation2006; Stevenson et al., Citation2007; Wald et al., Citation2007). Our findings provide one of the first demonstrations in a clinical setting that customizing educational materials to health literacy level and learning style preference improves patients' retention of health information. Given the chronic nature of hypertension, it will be important to determine whether the changes in learning are long-lasting. Research studies are needed to determine the generalizability of the findings to diverse populations and health care settings. Additionally, future work should be directed towards developing both rapid assessments of learning style preferences and semiautomated approaches to the generation and on-the-fly assembly of educational content, thus creating the infrastructure needed to scale the distribution of personalized health information materials into clinical settings.
Previous studies suggest that increased hypertension knowledge is associated with stronger adherence to medications (Kim et al., Citation2007) and better control of high blood pressure (Powers & Jalowiec Citation1987; Winkleby, Flora, & Kraemer, Citation1994; Wright-Nunes, Luther, Ikizler, & Cavanaugh, Citation2012). Studies have also shown that strategies designed to enhance patient education contribute to lower readmission rates (Hansen, Young, Hinami, Leung, & Williams, 2011). It is worth noting that the recently enacted Patient Protection and Affordable Care Act establishes reduced Medicare reimbursement for hospitals with high 30-day readmission rates (H.R. 3590—111th Congress, 2009). It is clear that showing an effect on readmission rates could make a compelling case for improving patient education.
Patients increasingly expect to act as proactive partners in the health care process. To optimize the delivery of health information, practitioners should be sensitive to all means of communication designed to enhance patients' knowledge of their conditions. Our study attempts to do so by providing an insight into a strategy that combines both learning style preferences and health literacy as key elements for learning. The encouraging findings of this investigation offer an outlet into an effective communication paradigm that could become critical to the ultimate goal of promoting a more person-centered approach to health care.
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This study was funded by a grant from the Institute of Museum and Library Services (IMLS LG-06-10-0186-10). The authors acknowledge Karen Miller, Sandra Martin, Dan McCollum, and Marcia Epelbaum for their assistance in the emergency department and Songphan Choemprayong for assistance during the manuscript preparation process.
Notes
Note. Percentages may not equal 100% because of rounding. S-TOFHLA = Short Test of Functional Health Literacy.
a Household income was not collected in the health literacy study.
b Health literacy level was measured using the S-TOFHLA in Experiment 1 and the Chew et al. questions in Experiment 2.
a The personalized materials given to patients in both studies did not contain all the information needed to correctly answer this question.
a Interviewer #3 in Experiment 1 is the same as Interviewer #1 in Experiment 2.
*p<.05 (two-tailed). **p<.001 (two-tailed).
Related Research Data
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