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Designing Dietary Education Materials for People With Chronic Kidney Disease: Recommendations for Improving the Quality of Resources

  • Kelly Lambert
    Correspondence
    Address correspondence to Kelly Lambert, PhD, School of Medical, Indigenous, and Health Sciences Faculty of Science, Medicine and Health, Building 41.309, Northfields Ave, University of Wollongong, Wollongong, New South Wales, 2522, Australia.
    Affiliations
    Adv APD, Senior Lecturer, School of Medical, Indigenous, and Health Sciences, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
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Open AccessPublished:July 02, 2022DOI:https://doi.org/10.1053/j.jrn.2022.06.005

      Objective

      The aim of this study is to quantify the readability, actionability, understandability, and overall quality of dietary education resources designed for patients and published in the Journal of Renal Nutrition.

      Design and Methods

      All patient education materials published in the “Patient Education” section of the journal from 2011 to 2021 were included. The readability, health literacy demand, and quality were evaluated using the Hemingway editor, Patient Education Materials Assessment Tool, and the Centers for Disease Control and Prevention Clear Communication Index (CDC CCI) respectively. Good quality materials were those with a reading grade level of ≤8; a Patient Education Materials Assessment Tool score of >70% (indicating materials were understandable and actionable), and a CDC CCI score >90%.

      Results

      A total of 42 resources were evaluated. Most materials (92%) were written at an appropriate level of readability (median grade 5, interquartile range [IQR: 5-7). The median understandability score was 71% (IQR: 60-81); however, only half (52%) of the materials met the 70% benchmark. Materials published performed poorly for actionability with the median actionability score of 37% (IQR: 20-83), and only 29% met the benchmark score. Overall quality was scored as low, with a median CDC CCI score of 65%, and only 10% of materials met the benchmark score. Areas for improvement were identified including providing a clear purpose, and summary of important points, explaining numbers and how to perform calculations, and including at least one action to take. Future efforts to improve actionability need to use the active voice, directly address readers, explain how to act, and describe the steps required.

      Conclusion

      Patient education materials that are attentive to health literacy principles beyond readability may enhance patient engagement, confidence, and empowerment, and improve adherence to the kidney diet.

      Keywords

      Introduction

      The year 2022 has been declared the year of “Kidney Health for All,” with a specific focus on efforts to improve education and awareness about kidney health.
      World Kidney Day
      WKD Theme 2021.
      This call-to-action advocates for increased provision of practical advice on diet and lifestyle to empower patients. A key part of nutrition education for people with kidney disease is the provision of dietary handouts to supplement the oral advice provided.
      However, people with chronic kidney disease (CKD) find dietary advice confusing, overwhelming, and burdensome.
      • Palmer S.C.
      • Hanson C.S.
      • Craig J.C.
      • et al.
      Dietary and Fluid Restrictions in CKD: a Thematic Synthesis of patient Views from qualitative Studies.
      Patients have also described adapting kidney diet handouts to better suit their needs.
      • Lambert K.
      • Mansfield K.
      • Mullan J.
      How do patients and carers make sense of renal dietary advice? A qualitative exploration.
      Given the evidence that inadequate health literacy is also present in one in 4 patients with CKD,
      • Taylor D.M.
      • Fraser S.D.S.
      • Bradley J.A.
      • et al.
      A systematic review of the prevalence and Associations of limited health literacy in CKD.
      and that patients have great difficulty finding appropriate self-management information to support their needs,
      • Lambert K.
      • Mullan J.
      • Mansfield K.
      • Lonergan M.
      A cross-sectional comparison of health literacy Deficits among patients with chronic kidney disease.
      it is important to evaluate the quality of publicly available materials used for dietary education.
      Only one study to date has formally evaluated the quality of written kidney diet information.
      • Doak L.G.
      • Doak C.C.
      Literacy levels of renal education materials.
      This study found that readability levels exceeded the skills of the average American. However, this research was conducted more than 3 decades ago. More recent research found that online kidney diet information frequently omitted details that supported behavior change.
      • Lambert K.
      • Mullan J.
      • Mansfield K.
      • Koukomous A.
      • Mesiti L.
      Evaluation of the quality and health literacy demand of online renal diet information.
      Given the prominent role of the International Society of Renal Nutrition and Metabolism in the World Kidney Day campaign, it appears timely to review the quality of patient education materials (PEMs) published previously in the Journal of Renal Nutrition. This information can be used by members and readers to identify areas for improvement in the design of future dietary education materials. The following were the specific aims of the project: (1) describe the readability level, (2) evaluate the understandability and actionability, and (3) overall quality of PEMs published in the Journal of Renal Nutrition in the period 2011-2021.

      Methods

      Materials published in the journal in the “Patient Education” section were downloaded from the journal website. Materials not eligible for evaluation were those materials not in English, published prior to 2011, <100 words, or not designed for patient education (i.e., were resources for clinicians).
      This desk-based content analysis used 3 tools. Readability was evaluated by pasting text from the materials into the Hemingway editor (https://hemingwayapp.com/). This online tool uses the Flesch-Kincaid readability formula
      • Kincaid J.P.
      • Fishburne Jr., R.P.
      • Rogers R.L.
      • Chissom B.S.
      Derivation of new readability formulas (Automtaed Readability Index, Fog count and Flesch Reading Ease Formula) for Navy enlisted personnel Millington, TN: Naval Technical Training, U.S, Naval Air Station, Memphis, TN.
      to calculate the reading grade level. The average American reads at 7th-8th grade level,
      U.S Department of Education
      Literacy, Numeracy, and Problem Solving in Technology-Rich Environments Among U.S. Adults: Results from the Program for the International Assessment of Adult Competencies 2012.
      so the goal for PEMs is for them to be written at an 8th grade level at most. Materials with a lower level are more desirable
      The Joint Commission
      Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals.
      as the average Medicare beneficiary in the United States reads at a 5th grade level.
      United States Government Accountability Office
      Report to Congressional Requesters. Medicare: Communications to Beneficiaries on the Prescription Drug Benefit Could Be Improved.
      The Patient Education Materials Assessment Tool (PEMAT) for written materials was used to determine the understandability and actionability
      • Shoemaker S.J.
      • Wolf M.S.
      • Brach C.
      The Patient Education Materials Assessment Tool (PEMAT) and User’s Guide. (Prepared by Abt Associates, Inc. under Contract No. HHSA290200900012I, TO 4).
      (referred to as health literacy demand). “Understandability” refers to health information that can be understood by health consumers from diverse backgrounds and varying health literacy levels.
      • Shoemaker S.J.
      • Wolf M.S.
      • Brach C.
      Development of the Patient Education Materials Assessment Tool (PEMAT): a new measure of understandability and actionability for print and audiovisual patient information.
      “Actionability” refers to content that enables the viewer to identify what they need to do.
      • Shoemaker S.J.
      • Wolf M.S.
      • Brach C.
      Development of the Patient Education Materials Assessment Tool (PEMAT): a new measure of understandability and actionability for print and audiovisual patient information.
      The PEMAT scores materials on a scale of 0-100, with a score of 100% indicating higher “understandability” and “actionability,” respectively. A score of >70% has been set by the authors of the tool as indicative of material that has low health literacy demand and is considered understandable and actionable.
      • Shoemaker S.J.
      • Wolf M.S.
      • Brach C.
      Development of the Patient Education Materials Assessment Tool (PEMAT): a new measure of understandability and actionability for print and audiovisual patient information.
      The written material version of the PEMAT includes 17 criteria for assessing understandability and 7 criteria assessing actionability.
      Finally, the CDC Clear Communication Index
      Centers for Disease Control and Prevention
      The CDC Clear Communication Index.
      was used to evaluate the quality of the material. This 20-item index includes assessment of the main message, language, information design, and behavioral recommendations. A score of ≥90% is ideal. The materials were evaluated by an experienced renal dietitian (K.L.). Basic descriptive statistics are used to describe the readability, health literacy demand, and quality. All analyses were conducted in SPSS (version 25; SPSS Inc, Chicago, IL).

      Results

      Figure 1 shows that a total of 72 articles were retrieved. After exclusion of ineligible PEMs, a total of 42 PEMs were assessed (see Table S1 for details of PEMs). The median readability of the written PEMs was grade 5 (interquartile range [IQR]: 5-7, range 2-12; Table 1). Most PEMs (92%) were written at grade 8 or lower. The health literacy demand of PEMs was suboptimal. Although the median understandability score was 71% (IQR: 57-81), only half (52%) exceeded the benchmark score. Actionability scores were substantially lower, with the median actionability score of 37% (IQR: 20-83). Only one-quarter (29%) exceeded the benchmark score of 70%. Table 1 shows areas where PEMs performed poorly. This included failing to explain the purpose of the PEM, not using the active voice, failing to use numbers in an easily understandable manner, and failing to provide a summary of the main message. Regarding actionability, most materials failed to directly address the reader, break down advice into simple steps, and importantly failed to explain how to use the information. Overall quality was scored as low, with a median CDC Clear Communication Index score of 65%, and only 10% of materials met the benchmark score.
      Figure thumbnail gr1
      Figure 1Flowchart of selection of PEMs. PEM, patient education material.
      From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097.
      Table 1Evaluation of Patient Education Materials Published From 2011 to 2021 in the Patient Education Section of the Journal of Renal Nutrition
      Total (n = 42)
      Readability
       Reading grade level, median (IQR)5 (5-7)
       Proportion meeting grade level 6-8 (%)92.3
      Health literacy demand
       Understandability
      Understandability total score, median % (IQR)71 (60-81)
      Understandability proportion exceeding benchmark 70%52.4
      Proportion meeting understandability criteria (%)
      Clear purpose50
      Avoids distractions81
      Uses plain language62
      Explains terms67
      Uses active voice57
      Easy to understand numbers52
      Not expected to perform calculations64
      Chunks information83
      Informative headings79
      Logical sequence86
      Summary provided10
      Visual cues used to highlight key points81
      Uses visual aids to help understanding62
      Visual aids reinforce content48
      Clear titles for visual aids45
      Clear images43
      Tables have row and column headings43
       Actionability
      Actionability total score, median (IQR)37 (20-83)
      Actionability proportion exceeding benchmark 70%28.6
      Proportion meeting actionability criteria (%)
      Describes one action to take74
      Directly addresses reader38
      Breaks down actions to steps26
      Provides tangible tool to help take action71
      Explains how to use visuals to take action17
      Uses visual aids to assist action57
       Quality
      CDC CCI total score, median (IQR)65 (53-82)
      CDC CCI proportion exceeding benchmark 90%9.5
      CDC CCI, Centers for Disease Control and Prevention Clear Communication Index; IQR, interquartile range.

      Discussion

      Many barriers to learning about the kidney diet exist for patients with CKD. These include the high prevalence of cognitive impairment,
      • Lambert K.
      • Mullan J.
      • Mansfield K.
      • Lonergan M.
      A comparison of the extent and pattern of cognitive impairment among predialysis, dialysis and transplant patients: a cross sectional study from Australia.
      low health literacy, a complex diet that changes over time, and limited staffing and time for education. Although no clear guidance exists specifically for the development of diet-related PEMs, we have evaluated the quality of kidney diet materials against best practice standards. The results suggest that there are several areas where improvements can occur. A summary of recommendations for the design of future PEMs are outlined in Table 2.
      Table 2Recommendations for Improving Kidney Diet Patient Education Materials
      Readability
      • Cut and paste text into an online readability calculator such as the Hemingway editor (https://hemingwayapp.com/) or Readability calculator (https://readabilityformulas.com/free-readability-formula-tests.php)
      • Use simple shorter words, e.g., eat rather than consume
      • Define any complex, vague, or not well understood dietetic words, e.g., portion (about the size of a deck of cards), enriched milk (milk with added milk powder), plenty, moderate, energy, serve, intake, balanced
      • Use short sentences, approximately 25 words in length
      • Chunk information into sections and use subheadings in the form of a sentence or question, e.g., “Why do I need a special diet?”. This allows readers to skim and better absorb information by including meaningful “signposts”
        Centers for Disease Control and Prevention
        Simply Put. A guide for creating easy to understand materials 2009.
      Health literacy demand
      • Understandability
        • Outline what the patient education material is for, e.g., “This handout is for people who need to follow a low potassium diet”
        • Limit the number of key messages to about three
        • Use the active voice, e.g., “You can continue to eat two pieces of fruit every day” rather than “Eat 2 serves of fruit everyday” or “Here are some tips you can use to help you gain weight” rather than “Tips to enrich your intake”
        • Include information in a logical order. Think about what the reader needs to know first, then second and third, e.g., Why do I need a special diet? What nutrients (and therefore foods) do I need to alter?
        • Arrange food lists in a logical order, e.g., “bananas, tomato, mango, chocolate” can be arranged into “fruit: banana, mango; vegetables: sweet potato; confectionary: chocolate”
        • Use bullet points with no more than 7 points in the list
        • Explain numbers (and how to perform calculations if necessary), e.g., “each serving of X has 200 mg and you can eat 3 of these each day”
      • Actionability
        • Clearly state the action you want the reader to take, e.g., “Drain all liquid from canned fruit to help lower potassium”
        • Explain why the behavior or action is needed, e.g., “Reducing how much salt you eat can help you lower your blood pressure”
        • Explicitly outline the steps the reader needs to take, e.g., “You can reduce how much salt you eat by looking at the nutrition information panel on packaged foods. Buy foods with no more than 120 mg of sodium per 100 g”
      Cultural sensitivity
      • Refer to cultural practices in the patient education material if appropriate, e.g., how to manage blood glucose levels during Ramadan
      • Choose images and meal/foods that represent the cultural profile of your target reader
      • Develop customized resources for common cultural groups with their input on important cuisine-related elements
      • Use qualified interpreters to translate materials to other languages and help ensure an accurate message is conveyed
      • When developing patient education materials, research the major and emerging language groups in your area
      • Consider including reference to common beliefs about food/eating/healing/illness that may be important to cultural groups in your care
      • Consider completing a cultural sensitivity dietetic assessment, e.g., https://metrosouth.health.qld.gov.au/sites/default/files/content/heau-clinician-assess-tool.pdf. This will help improve your awareness of ways to provide culturally responsive services
      Design and layout
      • Use wide margins and leave white space between sections
      • Use font size 12-14 and sans serif fonts such as Arial, Helvetica, Futura, Calibri to enhance readability
      • Simple line drawings with a lower level of detail may be more effective at conveying the main message and less distracting than infographics or multiple complex images
        • Findeis A.
        • Patyk M.
        Guidelines for Developing Patient Education Materials.
      • Label visuals with a caption to explain the message being conveyed
      • Consider use of color but be aware of combinations that are not differentiated for people who are color blind
        • Nersesian S.
        • Vitkin N.
        • Grantham S.
        • et al.
        Illustrating your research: design basics for junior clinicians and scientists.
      Other recommendations
      • Test your materials with your target patient group. What do they think are the key messages? Is this what you want to convey? Are there things they think are missing or should be included? Are there terms that need to be explained/clarified? Foods that they want included? Is the information in a logical order to them?
      • Use positive messaging in your summary of the main messages. Tell the audience what they will gain from using the material, e.g., “This diet sheet has shown you three ways you can reduce the amount of salt you eat. By making these changes, you can reduce your blood pressure, and help slow down progression of your kidney disease”
      • People with poor cooking skills may not understand common household measures or weights. Try and use alternative sizes instead, e.g., matchbox-sized piece, palm-sized portion, etc.
      • Always include a weblink and/or contact details to contact the clinician for more information
      • Dichotomous thinking is a barrier to behavior change.
        • Daundasekara S.S.
        • Arlinghaus K.R.
        • Johnston C.A.
        The importance of language in behavior change.
        Rather than using terms like “Foods to avoid” try alternative phrases, e.g., “Limit” or “Eat only occasionally”
      The art and science of designing PEMs is rapidly expanding. It is clear that PEMs are effective
      • Wallace A.S.
      • Seligman H.K.
      • Davis T.C.
      • et al.
      Literacy-appropriate educational materials and brief counseling improve diabetes self-management.
      and should be included as part of interactive educational sessions rather than provided as stand-alone passive dissemination strategies.
      • Grudniewicz A.
      • Kealy R.
      • Rodseth R.N.
      • Hamid J.
      • Rudoler D.
      • Straus S.E.
      What is the effectiveness of printed educational materials on primary care physician knowledge, behaviour, and patient outcomes: a systematic review and meta-analyses.
      New strategies such as gaining feedback directly from patients in a standardized approach should be incorporated as this is associated with improvements in health literacy demand.
      • Mastroianni F.
      • Chen Y.-C.
      • Vellar L.
      • et al.
      Implementation of an organisation-wide health literacy approach to improve the understandability and actionability of patient information and education materials: a pre-post effectiveness study.
      Although no formal cultural sensitivity assessment tool for dietary PEMs exists, dietitians should expand the types of food examples provided to enhance the cultural suitability of PEMs. This has been previously identified as a limitation by both dietitians
      • Lambert K.
      • Mansfield K.
      • Mullan J.
      Qualitative exploration of the experiences of renal dietitians and how they help patients with end stage kidney disease to understand the renal diet.
      and patients.
      • Lambert K.
      • Mansfield K.
      • Mullan J.
      How do patients and carers make sense of renal dietary advice? A qualitative exploration.
      PEMs should also proactively focus on diet quality and not just nutrients as outlined in the new KDOQI nutrition guidelines.
      • Ikizler T.A.
      • Burrowes J.D.
      • Byham-Gray L.D.
      • et al.
      KDOQI clinical practice guideline for nutrition in CKD: 2020 Update.
      In this study, most materials met the required level of readability. This is in contrast to the sole previous study.
      • Doak L.G.
      • Doak C.C.
      Literacy levels of renal education materials.
      However, it is now known that attention to the layout and design of PEMs is required because these factors affect comprehension, even in materials considered “readable.”
      Centers for Disease Control and Prevention
      Simply Put. A guide for creating easy to understand materials 2009.
      Other factors such as understanding how reader eye tracking changes in PEMs with single versus multiple columns is important (readers passively scan material on a page in an F-shaped pattern, using signposts to guide their reading and columns disrupt this pattern).
      • Doak C.C.
      • Doak L.G.
      • Root J.H.
      Teaching patients with low literacy skills.
      Clinicians should carefully consider which images are included in PEMs. Visual aids such as line drawings or photographs should be clear and not fuzzy, include captions, be representative of the target audience (age, gender, ethnicity), and importantly be closely linked to the concept being described. This has been shown to improve attention and comprehension and recall of information
      • Houts P.S.
      • Doak C.C.
      • Doak L.G.
      • Loscalzo M.J.
      The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence.
      Readers are encouraged to refer to Table 2 and Figure 2 as well as the other resources including the following:
      Figure thumbnail gr2
      Figure 2Example template of patient education materials using best practice health literacy and design principles.

      Practical Application

      Future PEMs should be attentive to readability, health literacy demand, be culturally sensitive, and follow appropriate design principles. This may enhance patient empowerment which is essential for patients to make adequate sense of and adhere to the kidney diet.

      CRediT Authorship Contribution Statement

      Kelly Lambert: Conceptualization, Methodology, Investigation, Formal analysis, Data curation, Writing – original draft, Final version of the manuscript.

      References

        • World Kidney Day
        WKD Theme 2021.
        https://www.worldkidneyday.org/2022-campaign/2022-wkd-theme/
        Date: 2022
        Date accessed: February 25, 2022
        • Palmer S.C.
        • Hanson C.S.
        • Craig J.C.
        • et al.
        Dietary and Fluid Restrictions in CKD: a Thematic Synthesis of patient Views from qualitative Studies.
        Am J Kidney Dis. 2015; 65: 559-573
        • Lambert K.
        • Mansfield K.
        • Mullan J.
        How do patients and carers make sense of renal dietary advice? A qualitative exploration.
        J Ren Care. 2018; 44: 238-250
        • Taylor D.M.
        • Fraser S.D.S.
        • Bradley J.A.
        • et al.
        A systematic review of the prevalence and Associations of limited health literacy in CKD.
        Clin J Am Soc Nephrol. 2017; 12: 1070-1084
        • Lambert K.
        • Mullan J.
        • Mansfield K.
        • Lonergan M.
        A cross-sectional comparison of health literacy Deficits among patients with chronic kidney disease.
        J Health Commun. 2015; 20: 16-23
        • Doak L.G.
        • Doak C.C.
        Literacy levels of renal education materials.
        J Ren Nutr. 1993; 3: 191-194
        • Lambert K.
        • Mullan J.
        • Mansfield K.
        • Koukomous A.
        • Mesiti L.
        Evaluation of the quality and health literacy demand of online renal diet information.
        J Hum Nutr Diet. 2017; 30: 634-645
        • Kincaid J.P.
        • Fishburne Jr., R.P.
        • Rogers R.L.
        • Chissom B.S.
        Derivation of new readability formulas (Automtaed Readability Index, Fog count and Flesch Reading Ease Formula) for Navy enlisted personnel Millington, TN: Naval Technical Training, U.S, Naval Air Station, Memphis, TN.
        http://www.dtic.mil/dtic/tr/fulltext/u2/a006655.pdf
        Date: 1975
        Date accessed: February 25, 2022
        • U.S Department of Education
        Literacy, Numeracy, and Problem Solving in Technology-Rich Environments Among U.S. Adults: Results from the Program for the International Assessment of Adult Competencies 2012.
        2012
        • The Joint Commission
        Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals.
        The Joint Commission, New York, NY2010
        • United States Government Accountability Office
        Report to Congressional Requesters. Medicare: Communications to Beneficiaries on the Prescription Drug Benefit Could Be Improved.
        2006
        • Shoemaker S.J.
        • Wolf M.S.
        • Brach C.
        The Patient Education Materials Assessment Tool (PEMAT) and User’s Guide. (Prepared by Abt Associates, Inc. under Contract No. HHSA290200900012I, TO 4).
        Agency for Healthcare Research and Quality, Rockville, MD2013
        • Shoemaker S.J.
        • Wolf M.S.
        • Brach C.
        Development of the Patient Education Materials Assessment Tool (PEMAT): a new measure of understandability and actionability for print and audiovisual patient information.
        Patient Educ Couns. 2014; 96: 395-403
        • Centers for Disease Control and Prevention
        The CDC Clear Communication Index.
        Centeres for Disease Control and Prevention, Atlanta, GA2021
        • Lambert K.
        • Mullan J.
        • Mansfield K.
        • Lonergan M.
        A comparison of the extent and pattern of cognitive impairment among predialysis, dialysis and transplant patients: a cross sectional study from Australia.
        Nephrology. 2017; 22: 899-906
        • Wallace A.S.
        • Seligman H.K.
        • Davis T.C.
        • et al.
        Literacy-appropriate educational materials and brief counseling improve diabetes self-management.
        Patient Educ Couns. 2009; 75: 328-333
        • Grudniewicz A.
        • Kealy R.
        • Rodseth R.N.
        • Hamid J.
        • Rudoler D.
        • Straus S.E.
        What is the effectiveness of printed educational materials on primary care physician knowledge, behaviour, and patient outcomes: a systematic review and meta-analyses.
        Implementation Sci. 2015; 10: 164
        • Mastroianni F.
        • Chen Y.-C.
        • Vellar L.
        • et al.
        Implementation of an organisation-wide health literacy approach to improve the understandability and actionability of patient information and education materials: a pre-post effectiveness study.
        Patient Educ Couns. 2019; 102: 1656-1661
        • Lambert K.
        • Mansfield K.
        • Mullan J.
        Qualitative exploration of the experiences of renal dietitians and how they help patients with end stage kidney disease to understand the renal diet.
        Nutr Diet J Dietitians Assoc Aust. 2019; 76: 126-134
        • Ikizler T.A.
        • Burrowes J.D.
        • Byham-Gray L.D.
        • et al.
        KDOQI clinical practice guideline for nutrition in CKD: 2020 Update.
        Am J Kidney Dis. 2020; 76: S1-S107
        • Centers for Disease Control and Prevention
        Simply Put. A guide for creating easy to understand materials 2009.
        • Doak C.C.
        • Doak L.G.
        • Root J.H.
        Teaching patients with low literacy skills.
        Am J Nurs. 1996; 96: 16M
        • Houts P.S.
        • Doak C.C.
        • Doak L.G.
        • Loscalzo M.J.
        The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence.
        Patient Educ Couns. 2006; 61: 173-190
        • Centers for Medicare and Medicaid Services
        Toolkit for making written material clear and effective 2021 [December 21, 2021].
        • Centers for Disease Control and Prevention
        Everyday Words for Public Health Communication 2016.
        • Findeis A.
        • Patyk M.
        Guidelines for Developing Patient Education Materials.
        in: Mechanick J.I. Kushner R.F. Creating a Lifestyle Medicine Center. Springer, Cham2020
        • Nersesian S.
        • Vitkin N.
        • Grantham S.
        • et al.
        Illustrating your research: design basics for junior clinicians and scientists.
        Br Med J. 2020; 370: m2254
        • Daundasekara S.S.
        • Arlinghaus K.R.
        • Johnston C.A.
        The importance of language in behavior change.
        Am J Lifestyle Med. 2019; 13: 239-242