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Web-Based, Pictograph-Formatted Discharge Instructions for Low-Literacy Older Adults After Hip Replacement Surgery: Findings of End-User Evaluation of the Website

Choi, Jeungok PhD, MPH, RN; Jacelon, Cynthia S. PhD, RN-BC, CRRN, FAAN; Kalmakis, Karen A. PhD, MPH, FNP-BC

doi: 10.1002/rnj.274
Continuing Education

Purpose: The purpose of this study was to develop web-based, pictograph-formatted discharge instructions and evaluate the website with intended users to maximize the relevance and clarity of the website.

Design: A descriptive study.

Methods: Low-literacy text and 45 sets of pictographs were implemented in web-based instructions. The content, design, function, and navigation of the website were reviewed by 15 low-literate older adults following hip replacement surgery.

Findings: Participants observed that the simple line drawings with clear background were well suited to web pages and helped to convey the points made. They also suggested changes such as adding an additional alphabetical index menu to enhance easy navigation and removing hypertext links to avoid distraction.

Conclusions: Web-based, pictograph-formatted discharge instructions were well received by low-literate older adults, who perceived the website easy to use and understand.

Clinical Relevance: A pictograph-formatted approach may provide effective strategies to promote understanding of lengthy, complex action-based discharge instructions in rehabilitation facilities.

College of Nursing, University of Massachusetts Amherst, Amherst, MA, USA

Correspondence: Jeungok Choi, College of Nursing, University of Massachusetts Amherst, 120 Skinner Hall, 651 North Pleasant Street, Amherst, MA 01003, USA. E-mail:

Accepted February 11, 2016.

Cite this article as: Choi P. J., Jacelon C. S., & Kalmakis K. A. (2017). Web-based, pictograph-formatted discharge instructions for low-literacy older adult after hip replacement surgery: Findings of end-user evaluation of the website. Rehabilitation Nursing, 42(5), 254–261. doi: 10.1002/rnj.274

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Discharge instructions, especially after hip replacement surgery, consist of recommended homecare actions, that is, “dos” and “don’ts.” However, in most cases, these home-care instructions have been provided in written text-based format, presenting a challenge for older adults, especially those with low-literacy skills (i.e., individuals with less than a 6th grade reading level). This is because (1) written text alone is not appropriate for presenting lengthy, complex discharge instructions with multiple actions and (2) low-literacy individuals tend to read word for word and to focus exclusively on each word and accessory details, giving a narrow field of view that may result in missing many key points (Doak, Doak, Friedell, & Meade, 1998 ; Doak, Doak, & Root, 1996). For these reasons, current healthcare providers’ strategy of easy-to-read instructions can only marginally improve low-literacy patients’ understanding.

To address this issue, we used a pictograph approach. Pictographs are simple line drawings showing explicit dis-charge healthcare actions. Our approach, based on the Cognitive Theory of Multimedia Learning (Mayer, 1999, 2001, 2002) is that using appropriate pictographs, in addition to simplified text, can improve a learner’s cognitive learning process and enhance his/her engagement in deeper understanding. This is due to humans cognitive preference for picture-based, rather than text-based, information. In addition, pictographs are well suited to show a step-by-step procedure that makes an entire homecare action sequence easier to learn when compared to explanations in text only. Using pictographs increases the likelihood that the discharge instructions are accurately interpreted by older adults after discharge to home (Hawley et al., 2008 ; Kripalani, Schmotzer, & Jacobson, 2012).

The first author developed 45 sets of pictographs and relevant text for the discharge instructions after hip replacement surgery (Choi, 2011b). Then, the text and pictographs were integrated into web-based discharge instructions using Adobe Dreamweaver and uploaded to the website ( To maximize the relevance and clarity of the web-based, pictograph-formatted discharge instructions, the website was tested with the end users, low-literate older adults who had had hip replacement surgery, for suitability of design, format features, and content. The purpose of this paper was to report the findings of end users’ evaluation of the pictograph-formatted discharge instruction website.

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Pictographs in Healthcare Practice

In the past, simple line drawings have been used in infor-mation leaflets as a tool to educate patients (e.g., preparing and administering treatment of dehydration, medication instruction, and diet regimen instruction). Several studies demonstrated that these simple line drawings were effective in improving comprehension and/or recall especially for adults with low literacy skills (Dowse & Ehlers, 2005 ; Houts, Witmer, Egeth, Loscalzo, & Zabora, 2001 ; Kripalani et al., 2007 ; Leiner, Handal, & Williams, 2004 ; Mansoor & Dowse, 2003). For example, Houts et al. (2001) developed pictographs for management for cancer and AIDS-related symptoms, targeting community-residing older adults with low literacy skills. They found significant improvement on recall (4 weeks after instruction) and comprehension using simple line drawings. In addition, Kripalani et al. (2007) developed a “pill card” to depict older adults’ daily medication regimen using pill images and icons and found that patients with inadequate to marginal literacy skills were more likely to initially refer to the card on a regular basis. Most pill card users (92%) rated the tool as very easy to understand, and 94% found it helpful for remembering important medication information, such as the name, purpose, or time of administration. Although these studies reveal promising findings on comprehension with simple line drawings (Dowse & Ehlers, 2005 ; Kripalani et al., 2007 ; Leiner et al., 2004 ; Mansoor & Dowse, 2003) and recall of healthcare instructions (Houts et al., 2001), they have some shortcomings. Simple line drawings have been used to represent static objects or concepts “associated” with healthcare actions (e.g., “taking medications” is presented as a drawing of pill bottles; Dowse & Ehlers, 2005 ; Kripalani et al., 2007 ; Mansoor & Dowse, 2003) as opposed to representing “explicit healthcare actions themselves” (e.g., a drawing of a person who is taking pills). Thus, older adults may not be able to accurately interpret the intended healthcare actions. Furthermore, some studies targeted community-residing adults using “hypothesized healthcare scenarios” (e.g., simulated medication and dose instructions; Houts et al., 2001). Therefore, the effect of simple line drawings from the studies described above may not translate well into discharge instructions in acute healthcare settings, which often consist of lengthy and complicated healthcare actions. None of the findings clearly portray patient experiences in a typical healthcare practice. The review of literature indicates a need for further research to include pictographs representing explicit healthcare actions. Further reviews about use of pictographs in healthcare practice can be found in a review study (Choi, 2011a).

Another important strategy for educating low-literate older adults is to adopt web-based mediums (Doak et al., 1996 ; National Institute on Aging & National Library of Medicine, 2009). Recent studies found that 53% of older adults aged 65 and older use the Internet (Zickuhr & Madde, 2012) and preferred receiving health information from this type of nonprint media (DHHS Office of Disease Prevention and Health Promotion [ODPHP], 2008). Indeed, 31%–49% of adults with below basic or basic health literacy receive some or most health information from nonprint media (DHHS ODPHP, 2008). Most importantly, web-based instructions are well suited for integrating a large number of simple line drawings and are more accessible and convenient when compared to paper-based instructions, which are often lost or damaged after discharge to home.

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Pictographs and Text for Discharge Instructions After Hip Replacement Surgery

The first author has previously developed 45 sets of pictographs and text for discharge instructions after hip-replacement surgery and integrated these into a discharge instruction booklet (Choi, 2011b). The text was created at the third-to-fifth-grade readability level measured by Fry readability formula (1968). The discharge instructions were designed in five sections: (1) overview of hip fracture and total hip replacement surgery, (2) advice about self-care, (3) prevention of complications and signs/symptoms of infections, (4) instructions for typical prescribed medications, and (5) guidance on when to seek medical help. Once the text was developed, the content was prioritized, and key topics were identified for creating pictographs. The actions of each topic were then represented in small steps. The instruction booklet was reviewed and evaluated for its appropriateness, accuracy, and relevance with nurse experts (Choi, 2011b), as well as its acceptability and comprehension with older low-literate adults (Choi, 2013). The nurse expert validators found that pictographs of stick figures were well suited for presenting action-based discharge instructions and perceived the pictographs as engaging and easy to understand (Choi, 2011b). Older adults perceived that the pictograph-based instruction booklet helped them understand the healthcare messages, particularly for instructions that required step-by-step procedures. The black-and-white simple line drawings were also well received by older adults regardless of their race and ethnicity (Choi, 2013).

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Development of Web-Based, Pictograph-Formatted Discharge Instructions

The text of discharge instructions was saved to a Microsoft Word file and converted to HTML file. Pictographs were saved as JPEG or GIF format, a flexible, adaptable format for illustrated graphics and excellent for resizing images without losing resolutions and details. The text and pictographs were then integrated into web-based discharge instructions using Adobe Dreamweaver, a web development application and uploaded to the website ( for further testing.

The sans serif typeface (Arial), developed specifically for web pages, was used. To maximize high-contrast color combination, black type against a white background was used with blue accents to draw attention to key informa-tion. The body of text was written in 14-point type, and users can adjust text size using the tool “Change Font Size.” For those who have questions about the content or want further information, additional tools such as e-mail updates are available, and website visitors can e-mail the author directly. A link to Medline Plus is also present. Using the link, website visitors can select helpful NIH website links (e.g., NIH Senior Health), which are written in easy language and targeted toward older adults. Guidelines for interface and instruction design for the website were derived from strategies suggested by the National Institute of Aging and National Cancer Institute (Chisnell & Redish, 2004, 2005 ; National Cancer Institute, 1994 ; National Institute on Aging & National Library of Medicine 2009 ; U.S. Department of Health and Human Services, 2006). The purpose of this paper was to report the findings of end users’ evaluation of this website.

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Evaluation of the Website With Low-Literate Older Adults


A convenience sample of 15 low-literate older adults recovering from hip replacement surgery was recruited from one rehabilitation hospital. The sample size is adequate because after recruitment of 13 participants there was data redundancy; no new comments emerged from the interviews (Grove, Burns, & Gray, 2012). Inclusion criteria were (1) ≥ 65 years old, (2) having marginal or inadequate health literacy (scoring ≤22 on the Short Test of Functional Health Literacy in Adults [S-TOFHLA]; Baker, Williams, Parker, Gazmararian, & Nurss, 1999), and (3) able to communicate in English. Patients were excluded if they (1) had visual acuity worse than 20/60 with glasses assessed by self-report or (2) demonstrated overt delirium, dementia, or any condition indicating deteriorating cognitive status as determined by the Mini-Cog (Borson, Scanlan, Brush, Vitaliano, & Dokmak, 2000).

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Health literacy was measured by the 40-item S-TOFHLA (Baker et al., 1999), which has two sections: reading com-prehension (36 items) and quantitative comprehension (numeracy, 4 items). The S-TOFHLA has been successfully used in community-dwelling and outpatient older adults with good internal consistency and reliability (0.70–0.97) (Baker et al., 1999 ; Campbell, Edwards, Ward, & Weatherby, 2007 ; Donelle, Hoffman-Goetz, & Arocha, 2007). Cognitive impairment was measured by the Mini-Cog (Borson et al., 2000), which combines the clock drawing test and three-word recall and has a high level of sensitivity (76%) and specificity (89%; Borson, Scanlan, Chen, & Ganguli, 2003). Unlike the Mini-Mental State Examination, the Mini-Cog is not adversely influenced by age, language, and education (Borson, Scanlan, Watanabe, Tu, & Lessig, 2005), making it a valid tool for low-literate adults whose education level is relatively low.

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Once the study was approved by the institutional review boards at the university and the participating hospital, potential participants, who were referred by a nurse manager in the hospital, were invited to participate. Those who agreed signed the informed consent. Participants were then screened for inclusion and exclusion criteria using the S-TOFHLA and the Mini-Cog.

After participants were discharged to home, they were contacted to schedule an interview. The interviews took place in participants’ home, community rooms in the public libraries, or in town halls near participants’ homes. The interviews began with verbal instructions from the first author. To ensure that the instructions were uniformly presented to all participants, the first author prepared a written package to guide interview sessions. The package contained information about the purpose of the interview, an explanation of pictographs, and standardized conventions for meanings in pictographs (e.g., a red lightning bolt indicates pain). Next, the participant and the researcher reviewed the website, and the participant was asked if the website was (1) clear and understandable, (2) easy to use, and (3) responsive to the older adults’ needs and concerns. The participants were also asked to provide suggestions to improve the website. During the interview, the participants were encouraged to “think aloud,” which is to verbalize what they were thinking (Jaspers, Steen, van den Bos, & Geenen, 2004 ; Sharp, Rogers, & Preece, 2007) and to be as specific as possible in their comments/feedback. The researcher gently reminded them to “think aloud” when they seemed reluctant to speak or they were silent during the interview. The researcher documented the participants’ comments in a Word file on a laptop computer. At the end of the meetings, the researcher returned the comments back to the participants to discuss if the comments reflected their experiences and revised them if there were any discrepancies. Each interview took approximately 30 minutes.

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Data Analysis

Data were analyzed using content analysis (Elo & Kyngäas, 2008). Data in a Word file were coded. To develop codes, the researcher read through the printed Word file, marking the keywords or phrases as highlighted. The researcher then created a list of codes and refined further by combining or removing repetitious or similar topics (Grove et al., 2012). Codes were sorted into four categories: (1) design and layout, (2) navigation, (3) function, and (4) content for text and pictographs.

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Participants were 65–74 years old, and most had a high school or equivalent diploma (n = 13, 86.6%). More women participated in the study than did men (n = 9, 60%). Participants were racially diverse (60.0% White, 20.0% African-American, 6.7% Asian/Pacific Islander, 13.3% Hispanic origin). No participants were screened positive for cognitive impairment measured by the Mini-Cog. Participants’ mean S-TOFHLA score was 17.1 (SD = 4.3), indicating marginal or inadequate health literacy (Table 1).

Table 1

Table 1

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Findings From Older Adults’ Evaluation

Participants offered 53 comments or suggestions during the interviews. Most of these pertained to the text and the pictographs (n = 20, 37.7%), as well as the design and layout (n = 14, 26.4%). Comments about navigations (n = 10, 18.9%), functions (n = 8, 15.1%), and others (n = 1, 1.9%) comprised the remaining comments and suggestions.

Overall, older adults found that the simple line draw-ings, with clear background, were well suited to web pages. The simple line drawings helped to convey important points made, and the language was simple and clear with the large headings, making the instructions easy to understand. Participants specifically liked the facial expressions in the images, which provided clues to whether the position or action was good or bad.

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Participants’ Comments

Participants described the design and layout as straight-forward and without distractions. In terms of navigation, participants described the website as simple to follow and easy to navigate. The functions were considered basic and easy to use, and the tool to change the font size was very helpful for those with low vision. In addition, participants reported finding the educational links in the additional information section on the home page useful because they facilitated the search for more in-depth information on hip replacement care.

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Suggestions to Improve the Website

The participants also provided suggestions to improve the website. In the design and layout of the web pages, participants found the home page crowded with too many words and sentences. To improve navigation, they suggested removing the hypertext links, because these links were distracting and prevented them from making smooth transitions within the web pages. They also recommended an alphabetical index menu be included on the home page. With regard to functions of the web pages, participants suggested a tool to increase the size of the picture, similar to the tool for font size, would be helpful. In the content for pictographs and text, older adults found that the “what not to do” or “no” messages needed to be more clear to avoid confusion between what should and what should not be done. They also commented that several pages were difficult to read because the content was too lengthy. Several participants were concerned that the disclaimer, copyright, and privacy statements on the website used technical terms and jargon, making the information difficult to understand. Last, there was a concern about the difficulties in pronouncing medical terms. Although older adults agreed the readability was appropriate and they were able to understand most of the information, many had difficulty pronouncing certain medical terms or medication names such as warfarin. They suggested adding audio pronunciations to medical terms or medication names to help pronounce these medical terms and names correctly.

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Revision of the Website

Participants’ feedback and suggestions were incorporated into the final website. For example, to simplify the menu structure and facilitate easy navigation, an alphabetical index menu called “Discharge Instruction Topics by First Letter” was added on the home page. All the hypertext links within the text were removed. “What not to do” or “no” messages were emphasized using red font. The lengthy web pages were divided into separate web pages, and relevant text passages were reorganized to address related topics. In addition, the disclaimer, copyright, and privacy statements were revised by removing technical terms and jargon. Changes in the website to add audio files are currently under way. Figure 1 shows sample screenshots of the final website.

Figure 1

Figure 1

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In this paper, we have reported the findings of older adults’ evaluation of the web-based pictograph-formatted discharge instructions for hip replacement surgery. The sample of older adults interviewed, perceived the simple line drawings with clear background were well suited in web pages, and that the website was easy to use. They provided suggestions to improve the website including an additional alphabetical index menu to enhance easy navigation and text reorganized to present smaller bits of information at a time. Based on the feedback and suggestions, the website was revised and finalized.

Three main issues were identified. First, although older adults perceived that the website was easy to use and the text and the pictographs were understandable, they found the disclaimer, copyright, and privacy statements in the website were too technical, thus difficult to understand. Several participants were offended by the tone and complexity of the wording, for example, “It is not the intention of our website to provide specific medical advice, but rather to provide users with information…. Specific medical advice will not be provided, and we urge you to consult with a qualified physician for answers to your personal questions.” The wording and the tone of the content for the disclaimer was changed using plain language that is more user-friendly and nonoffensive, for example, “The above list of resources is only a suggestion and is not a complete listing of hip-replacement postsurgical care materials or information. The information contained herein is not meant to be used for self-diagnosis or to replace the services of a doctor or other health care professional.” In a review of 50 websites for older adults, Chisnell and Redish (2005) reported that some websites include a disclaimer about using the drug or health information on the site for purposes other than personal information. The results of this study are congruent with the findings of Chisnell and Redish (2005), indicating that such disclaimers may be perceived as too threatening, and in fact, older adults may stop using the website. Although it is important to clearly provide disclaimers on health websites, the statement should not be offensive or threatening for older adults.

The second issue emphasized by older adults was the importance of detailed instruction for specific features of the website such as alphabetical index menu and a free-text search field. Although low literacy does not necessarily indicate computer literacy, the two are likely to be closely related (Almader-Douglas & Eberle, 2013). Considering the target population of the website (older adults with low health literacy), instructions for all design features should be clearly explained in step-by-step format. The best way to teach the skills needed to use specific features may be user training sessions demonstrating how to execute each feature.

The third issue was simplicity in navigation associated with use of hypertext links. A common theme from study participants was “simplicity” in design (e.g., limited use of colors, one font type and size), content (e.g., chunking a lengthy text into several smaller sections), and navigation (e.g., avoid use of hypertext links). Older adults were concerned that complicated hypertext links within the text were distracting, causing them to be confused. Hypertext links (blue underlined text linking to other resources) are the most common tool adopted by most educational websites, because they provide better visual prominence and browsing capability. However, our findings are consistent with the findings of Lin (2004), who reported hyperlinks may cause older adults to become lost as they move through hypertexts. This difficulty in staying on track given the option to diverge down another path of information is called hypertext disorientation. A careful use of hypertext links is suggested when developing websites for older adults with low-literacy skills.

Several limitations need to be considered when inter-preting the results of this study. The credibility of study findings may be limited because coding of data was done by one coder, the researcher. To enhance validity and certainty of the findings, having a second coder and checking intercoder agreement is suggested (Morse, 2015). In addition, although member checking was done at the end of each interview to ensure credibility of the findings, more strategies such as peer debriefing and reflexivity journal or diary are suggested to improve trustworthiness of the findings (Grove et al., 2012).

Future research is suggested to examine the effective-ness of web-based, pictograph-formatted discharge instructions in low-literate older adults. Such research should use a randomized controlled trial design to assess comprehension and adherence to discharge instructions, as well as health outcomes such as complications (dislocation of the hip replacement, infection in the incision, and blood clots in legs) and ED admission/hospital readmission. Replicating the study findings for immigrants and refugees are also suggested because these populations might benefit the most from the pictograph-based discharge instructions.

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Our findings show that pictographs (simple line drawings using stick figures) are well suited for web pages. Older adults in our study perceived web-based, pictograph-formatted discharge instructions to be easy to use and helped them understand the intended healthcare information. They also suggested changes for improvement, which included an alphabetical index menu to enhance easy navigation, a tool to enlarge pictographs, and an audio link to pronounce medical words.

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Clinical Implications

Discharge education designed for low-literate older adults is critical to improving health outcomes. This education may lower complication rates and lower healthcare costs by avoiding complications. web-based, pictograph-formatted discharge instructions hold promise in providing an effective strategy for older adults to better understand lengthy, complex action-based discharge instructions, especially in rehabilitation practice settings where nurses have primary responsibility as a first line of healthcare educators.

The pictograph-formatted discharge instructions can be used across different settings of care. Rehabilitation nurses may provide pictograph-formatted materials as a part of routine discharge education. Training and educating a rehabilitation team (e.g., discharge nurses, physical therapists, occupational therapists, and visiting nurses) at inpatient and homecare settings can be an important strategy to widely disseminate pictograph instructions for patients after discharge to home. Homecare support by family caregivers is an essential component of patient recovery; therefore, inclusion of family caregivers in education sessions on discharge instructions can be a strategy to improve patients’ adherence to pictograph instructions at home. Finally, nurses can encourage patients to access the website by providing them a Universal Serial Bus (USB) webkey. The webkey can store the website address and automatically launch the website when older adults plug-in the key into a USB port; thus, users do not need to remember a lengthy URL for the site.

The pictograph approach can also be used to develop healthcare education materials for immigrants and refugees when language barriers present significant communication challenges. Recent immigrants and refugees are increasingly diverse, emigrating from more than 60 countries and speaking over 20 primary languages (Nwosu, Batalova, & Auclair, 2014). Addressing the communication needs of such diverse populations through interpreters and pretranslated healthcare materials is impractical and inefficient. Pictograph-formatted instructions may provide a more efficient and practical strategy to address communication challenges for populations who experience low literacy, whether they are older adults or immigrants and refugees for whom English is a second language.

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Key Practice Points

  • Current forms of written text-only discharge instructions are not suitable for presenting lengthy, complex discharge instructions.
  • Pictographs (simple line drawings showing explicit discharge homecare actions) can show a step-by-step procedure and make an entire action sequence easy to learn, so the discharge instructions can be accurately resembled after discharge to home.
  • Web-based, pictograph-formatted discharge instructions after hip replacement surgery were well received by the intended user of the website, low-literate older adults who perceived the website easy to use and helped them understand the intended discharge instructions.
  • Web-based, pictograph-formatted discharge instructions may provide effective strategies to improve discharge communication for low-literate older adults, especially in rehabilitation practice settings where nurses have primary responsibility as a first line of healthcare educators.
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This project was partially supported by the American Nurses Foundation, Association of Rehabilitation Nurses (Choi, 2011). The authors thank Katelyn Thompson for building the Web pages. The authors declare no conflict of interest.

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Patient discharge; health literacy; aged; arthroplasty; replacement; hip; descriptive study; web-based instructions; pictographs; low literacy

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