Introduction
Menopause, as a natural phenomenon and a physiological transition in middle-aged women, is individually, socially, and culturally important. It is associated with complications and consequences that can affect women’s quality of life and weaken the good and healthy feeling in them [1]. Health education interventions are one of the alternative strategies for promoting health and coping with menopausal symptoms [2]. Studies have shown that the severity of the menopausal symptoms is associated with low educational levels, low socioeconomic status, race, frequency of deliveries, and high age at the menopause onset [3]. Therefore, the acceptance and management of menopausal symptoms and the enhancement of women’s health literacy have been considered. Health literacy is the ability to obtain, read, understand, and use the information in order to make appropriate health decisions and follow instructions for treatment [4]. Increasing people’s knowledge and health literacy can help them in facing health problems [5]. Poor health is an independent risk factor for low use of preventive services, higher hospital admission, medication non-adherence, and mortality, and is a consequence of inadequate health literacy [6]. Studies have shown that more than one-third of adults have inadequate proficiency in health literacy tasks [7]. Primary sources of health information are physicians and health professionals, but for reasons such as lack of time, large numbers of clients, high medical costs and poor communication skills, these specialists are not always able to meet patients’ information needs [8]. Health information resources in different formats such as pamphlets, booklets, brochures, and with a variety of purposes such as developing self-care skills, increasing awareness about diseases, and increasing awareness of the availability of medical and health facilities are used as a complementary component in training programs [9, 10]. Educational materials are frequently used by health providers and have advantages such as portability and consistency [11]. Much of this information is forgotten, when only oral information is provided. Thus health providers are encouraged to prepare printed educational material for people to reinforce and supplement the information that has been provided orally [12]. Audience comprehension is the main goal of educational resource producers. In the process of understanding, people first receive different input stimuli and information and send it to the brain; secondly, these recorded stimuli are processed. Thirdly, this information is understood by making some neurochemical changes in the brain. if the received stimuli in the first step not properly recorded, the second and third stages do not occur and therefore the understanding is not achieved [13, 14]. Some standards are being established to enhance the quality of patient education materials, such as recommendations to write educational materials at a sixth-grade reading level [15]. The instruments used to assess the appropriateness of printed material are readability and suitability. Readability refers to the ease or difficulty of reading an educational medium. However, readability alone is not enough for improving perception. Suitability offers a systematic method to objectively assess the suitability of health information materials for a particular audience in a short time [16].
Most postmenopausal women do not have adequate information about menopausal symptoms and are not aware of the strategies to control their side effects [17-19]. The first step in promoting the women’s compatibility and compliance with the menopausal changes is to enhance their awareness about the physiological process and the body functions. Awareness about the signs and symptoms of menopause can help women to live a comfortable and happy life. It also alleviates their psychological problems [20]. In 1990, the world’s population of women over 50 was 467 million, which is estimated to increase to 1,200 million by 2030 [21]. In 2011, there were 7,539,293 women aged 40-60 years in Iran [22]. Symptoms observed in postmenopausal women include hot flashes, sweating, palpitations, sleep disorders, irritability, lethargy, depressed mood, forgetfulness, decreased libido, depression, vaginal dryness, painful intercourse, urinary symptoms, memory reduction, decreased concentration, restlessness, as well as joint and bone problems [23]. The increasing population of elderly in Iran and prevalence of all kinds of health problems and menopausal symptoms in these ages can affect work, social activity, enjoyment of life, leisure time, sleep and quality of life of women and their families and endanger the health integrity and health of postmenopausal women [24]. So it is necessary to use educational materials to educate post-menopausal women about the healthy life styles that can affect the severity of menopause symptoms. For all target groups, printed educational materials for health issues will be useful, if it is understood by the recipient [25]. Little attention has been paid to the readability and suitability of these educational materials for postmenopausal women. Assessment of written educational materials about menopausal hormone therapies showed that most of the materials are written at a high reading level [26]. In some studies conducted in Yazd regarding menopausal health education, the used media for intervention has not been evaluated [27-29].
While results from the National Adult Literacy showed that one in four adults in the United States have low reading level [30], the readability and suitability of education materials for postmenopausal women remains relatively unexplored. To address this gap, the specific aim of this study was to determine the readability and suitability of education materials in promoting the quality of life for postmenopausal women.
Material and methods
Study design and population
This study was conducted in 2019 (14 September – 22 October) in Yazd, located in the center of Iran. The participants enrolled in this study were 15 postmenopausal aged between 45-55 years old, 5 postmenopausal women family members (3 husbands and 2 children), and 5 health experts (2 health education specialists and 3 educational technologists). In order to select 15postmenopausal women, three health care centers were selected randomly in Yazd city. Then participants were chosen randomly from the list of the clients. In this study, printed educational materials, included pamphlets about improving menopause quality of life and daily activities’ booklets to monitor daily activities. In order to evaluate the appropriateness of the prepared printed educational material, readability and suitability tools were used. The readability of the material was assessed by the “readability assessment of materials” (RAM) and suitability was accessed through the “suitability assessment of materials” (SAM). Initially, the educational materials were evaluated technically by the experts. Then, according to their points of view, the necessary changes were made and the materials were tailored according to the target group. Tailored material was then returned to the target group and the suitability and readability were assessed again.
Readability assessment of materials
RAM assesses the difficulty of reading an educational medium in three parts, which are having a specialized content (range of scores 0-6), misspelling (range of scores 0-6), and typographical mistakes (range of scores 0-6). The range of scores in media readability assessment is from 0 to 18 and the acceptable score is more than 10 [31].
Suitability assessment of materials
Suitability was measured using the SAM created by Doak et al. [15]. The SAM is a systematic tool to assess printed health-related educational resources in a short amount of time. The SAM has been validated [32] and successfully used in prior studies of other printed health information [33, 34]. The SAM consists of 6 evaluation criteria: content (e.g., “behavior information to help solve their problem”), literacy demand (e.g., “common, explicit words are used”), graphics (e.g., “simple, adult-appropriate, line drawings/sketches are used”), layout and typography (e.g., “type size is at least 12 point, no ALL CAPS for long headers or running text”), learning stimulation and motivation (e.g., “complex topics are subdivided into small parts so that readers may experience small successes in understanding or problem solving”), and cultural appropriateness (e.g., “images and examples present the culture in positive ways”).
Three readers were trained in the SAM scoring techniques. Each reviewer scored all study materials and was blinded to the source of the material. The mean SAM scores were used in the analysis. The SAM consists of 22 items grouped under six factors, namely content, literacy demands, graphics, layout and typography, learning stimulation and motivation, and cultural appropriateness. Each of the 22 items is rated in terms of the degree to which it meets set criteria, on an ordinal scale of 0, 1, 2, and not applicable, where 0 = inadequate, 1 = adequate, and 2 = superior. Scores are summed to yield an overall raw score for the material. This is converted to a percentage of the possible total score for that material, with 70-100% being considered to be superior material, 40-69% adequate material, and 0-39% not suitable material [15].
Statistical analysis
The Kolmogorov-Smirnov (KS) test was used to check the normality of quantitative variables and showed that the data had a normal distribution. The collected data were analyzed by SPSS software version 22. Descriptive statistics were reported for all variables. The mean score of SAM and RAM before and after tailoring was compared using paired t-tests. The level of significance in the tests was considered less than 0.05.
Ethical approval of studies and trial registration
Ethical approval for this study has been obtained by the ethics committee affiliated with Shahid Sadoughi University of Medical Sciences, Yazd, Iran (reference number IR.SSU.SPH.REC.1397.137) and date (02/02/2019). Registration of this randomized control trial has been completed with the Iranian Registry of Clinical Trials, IRCT20190206042640N1.
Results
Out of 20 participants in the study, 15 people were postmenopausal aged between 45-55 years old, 5 people were postmenopausal women family members (3 husbands and 2 children), and 5 people were health experts (2 health education specialists and 3 educational technologists).The mean age of the women were 51 ±2.43. Among the participants 85% were women, 60% of women were in high school or less education level (Table 3).
Table 1
Readability assessment of materials (RAM)
[i] Scores range of RAM: minimum and maximum score: 0-18, acceptable score: score over 10 [31]
Table 2
Suitability assessment of materials (SAM)
Table 3
Demographic characteristics of participants
Out of 20 participants in the study, 15 people were postmenopausal aged between 45-55 years old, 5 people were postmenopausal women family members (3 husbands and 2 children), and 5 people were health experts (2 health education specialists and 3 educational technologists).The mean age of the women were 51 ±2.43. Among the participants 85% were women, 60% of women were in high school or less education level (Table 3).
The mean readability score ±standard deviation (SD) of the educational materials were 10 ±1.6 and 8 ±1.4, for the pamphlet and daily activities’ booklets, respectively, which were increased to 14 ±0.6 and, 16 ±1.3, after tailoring the content (Table 4).
Table 4
Mean score of the readability assessment of materials before and after tailoring
| Readability score | Materials | |
|---|---|---|
| Pamphlet | Daily activities’ booklet | |
| Before | 10 ±1.6 | 8 ±1.4 |
| After | 14 ±0.6 | 16 ±1.3 |
The average SAM scores before and after tailoring the content were 45% for the pamphlet, which was increased to 81%. The increase in all scores was significant (p < 0.001). Those findings showed the final educational material was “superior media” on the SAM ratings (Table 5).
Table 5
Results of the assessment pamphlet suitability assessment of materials (SAM) score check list before and after tailoring
The average SAM score for daily activities’ booklets was 45%, which significantly was increased to 86% after tailoring the content. Those findings showed the final educational material was “superior media” on the SAM ratings (Table 6).
Table 6
Results of the assessment daily activities’ booklets suitability assessment of materials (SAM) score check list before and after tailoring
Discussion
Annually large budgets are being spent in the production of educational materials but little attention is paid to the appropriateness of these materials for the target group. The pamphlet in this study addressed a variety of topics including the definition of menopause, menopause symptoms, Common complications during menopause, Useful strategies to reduce menopausal symptoms and daily activities’ booklet is a notebook that a postmenopausal woman should tick her daily activities. A study by Abdolmalaki et al. in Iran found that a high percentage of postmenopausal women (48.7%) do not have good health literacy. It should be noted that women need to have enough information to judge whether their symptoms need to be treated and how to monitor medical care [35]. So consideration of the level of health literacy of the target group is essential in the preparation of educational materials.
The present study aimed to determine the readability and suitability of postmenopausal women education material in promoting the quality of life. Readability refers to the ease of comprehension of printed material with respect to its writing style [36] and suitability assessment can be used to evaluate printed materials against factors known to enhance people’s understanding of printed materials [15]. In this study, analysis of suitability indicated that pamphlet and daily activities’ booklets were in the adequate range before the tailoring that enhanced to superior range after tailoring, while analysis of readability showed pamphlet was in acceptable range before and after tailoring but daily activities’ booklets wasn’t in acceptable range before tailoring that enhanced after tailoring. This finding is consistent with results from the Sadeghi et al. study in Iran about the readability and suitability assessment of adolescent education materials in preventing hookah smoking [37], Hoffmann et al. in Australia about assessing the suitability of written stroke materials: an evaluation of the interrater reliability of the SAM checklist [12] and Rhee et al. in the USA about the educational material about rheumatic diseases [16]. However, the results of Walsh and Volsko in the USA about the readability assessment of internet-based consumer health information [38], is not consistent with this study and the educational material assessed in their study did not have proper readability. SAM instrument offers a systematic method to objectively assess the suitability of health information materials for a particular audience in a short time [38]. In this study, the SAM mean score was increased after correction and tailoring the content. Hoffmann et al.’s study in Australia about assessing the suitability of written stroke material was in line with our findings and showed printed materials enhance people’s understanding [12]. Finnie et al. in a systematic review showed only two of the seven Cancer Education Print and Web-based materials were suitable [39]. In this study, the average SAM score for pamphlet and daily activity booklet was 45%, before the tailoring, which is considered “adequate” on the SAM ratings also in Weintraub et al. study titled an evaluation of the written education materials for patients with prostate cancer, the mean overall SAM rating was “adequate.” However, average scores were higher (63.3%) in comparison to our study [34]. The mean readability level of materials in Eames et al. study titled “The Suitability of Written Education Materials for Stroke Survivors and Their Carers was (grade 9) higher than participants” mean reading ability (grade 7-8) [40], while the mean score of readability of pamphlet in this study was acceptable (> 10) that is not consistent with Eames’s study but This finding is consistent with results from the Sadeghi et al. study [37]. Thus modifying printed educational material and tailoring them according to the target group is important for facilitating learning and recall of the information. A limitation of this study was the small sample of participants (n = 20) which may not be representative of all postmenopausal women and their needs.
Proper planning should be done for the production and distribution of educational media in accordance with the readability and suitability standards. Also, health educators who prepare education materials should be trained for this goal.
Conclusions
We recommend that guidelines for designing educational materials should be established. Health educators should strive to ensure that the quality of the printed education materials is appropriate for the target group and also should evaluate the printed educational materials by doing pilot study prior to dissemination. SAM checklist can be used to identify the proportion of education materials provided to the target group and also RAM checklist can determine the readability level of the target group. The findings showed that the printed educational materials were enhanced after evaluation by the RAM and the SAM checklist and they were in accordance with the characteristics of the postmenopausal women. Compliance with these recommendations may increase the likelihood of consumer perception and recall.
