This pilot study allowed the research team to investigate the conceptual feasibility of a learning style–tailored information prescription. While prior hypertension educational intervention studies have focused largely on adapting materials to health literacy levels, few studies have incorporated learning-style preferences into health communication practices. In a survey of ninety-nine caregivers of asthmatic children, Dinakar et al. utilized the VARK questionnaire to characterize learning preferences to inform education activities [25
]. Boyde et al. used the VARK to assess learning preferences of heart failure patients and provide recommendations for educational needs [26
]. Carbone et al. piloted the use of tailored diabetes education activities, customized to individual literacy levels and learning styles, with ten Spanish-speaking adult patients with type-2 diabetes. Investigators used results from cognitive interviews to ascertain which learning activities were easiest or most difficult for study participants. Specific behavioral and clinical outcomes were not measured; however, their results contributed preliminary understanding of how this approach can inform patient education [27
In the current study, results do not indicate a significant change between the intervention and control groups in knowledge of hypertension issues two weeks post-ED-visit, but descriptive analysis of patient subgroups provides useful indicators for which patients might best benefit from this customized learning approach. While a larger sample would be required for a definitive conclusion, the personalized information prescription content appears to have improved hypertension knowledge for persons with a high school education or less. This is not surprising as lower educational status, often a marker for lower socioeconomic status, is associated with increased hypertension prevalence rates and may signal a patient population with greater information needs [28
]. Additionally, the data suggest that the intervention had a greater effect on men than women. This might result from different information-seeking behaviors between the two groups. Anecdotal patient feedback and quiz results suggest that female participants in the control group might have researched hypertension information on their own prior to completing the follow-up survey. These results are in keeping with published research indicating women have higher rates of information-seeking behavior [30
]. A larger sample, which would permit a multiple regression analysis, would be useful to shed further light on potential interactions between these demographic variables and knowledge outcome scores. While not specified in the a priori statistical analysis plan, this technique may be employed in future studies using this intervention.
Mean baseline hypertension knowledge scores were high in both arms of the study, leaving little room for increase in scores at follow up. An analysis of responses on the hypertension quiz revealed that study participants knew the correct answers to many of the questions at baseline: Only three of the questions were answered incorrectly a majority of the time by both control and intervention participants. This finding can inform the future development of weighted scoring algorithms for calculating hypertension knowledge scores.
Response item analysis also sheds light on an additional component of the study process. Interestingly, quiz results for the statement regarding stress as a cause of high blood pressure showed a decrease in the number of correct responses among patients in the intervention group at follow up. NHLBI education materials given to patients discussed long-term stress as a contributor to high blood pressure, whereas the official NHLBI answer to the question, “Stress causes high blood pressure” (true/false), is “False.” The question posed to study participants did not make a distinction between short- versus long-term stress, thus it is understandable that patients would perceive stress as not only a contributor to but as a cause of high blood pressure. This perhaps explains the direction of the scores on this quiz item. In contrast, scores on the quiz item with the second-lowest baseline score, “High blood pressure has no cure,” showed the greatest improvement at follow up, thus creating optimism for improving hypertension knowledge. A future study design that will not only utilize a weighted scoring methodology to allow more importance for specific questions, but also include questions with increased complexity to provide more room for improvement in baseline scores.
Hypertension was previously diagnosed in 87% (27/31) of the intervention group members who completed the follow-up survey. At follow up, 61% (19/31) of these patients reported already knowing the information contained in the intervention materials. The gap between patients diagnosed with hypertension (n
27) and the number reporting prior knowledge of the provided hypertension information (n
19) further supports the need for increased patient education.
Results from the item response analysis of the hypertension quiz suggest limitations in its ability to satisfactorily discriminate potential knowledge differences, because nine of twelve questions were answered correctly a majority of the time. Further research to develop a validated hypertension knowledge measurement instrument for the ED setting could potentially provide greater accuracy in determining knowledge changes.
Primary outcome results in hypertension knowledge scores differed by gender, with women in the control group demonstrating higher scores two weeks post visit than men. The follow-up interview did not include a question designed to ascertain information-seeking practices of participants, and therefore the study team was not able to directly compare self-reported behaviors against knowledge score outcomes. Modifications of the post-ED-visit survey to include this question will allow the team to independently assess the effect of external inquiring or searching behavior on follow-up outcomes.
Patients receiving intervention materials reported higher levels of satisfaction than those receiving standard discharge instructions. The higher scores may possibly be confounded by the method of delivery rather than the information itself, because control group participants received information in a more routine manner than the intervention group. However, since health communication exchanges between providers and patients can undoubtedly benefit from more personalized approaches, the intervention might positively affect patient perceptions of their overall health care team.
In this pilot study, the team provided the intervention via one learning mode, yet patients can exhibit multimodal learning preferences. Future efforts to use information delivery formats encompassing multimodal learning styles (e.g., combining kinesthetic with aural preferences or read/write with visual preferences) is likely to provide greater patient benefit. Additionally, an individual's ability to learn and act upon new information is undoubtedly influenced by a variety of factors other than specific learning-style preferences. However, addressing learning-style preferences eliminates one potential barrier in health communication practices.