A Formal Evaluation of Existing Printed HPV Educational Materials Heather M. Brandt, PhD, CHES1 Donna H. McCree, PhD, MPH, RPh2 Lisa L. Lindley, DrPH3 Patricia A. Sharpe, PhD, MPH1 1University of South Carolina Prevention Research Center, Columbia SC USA 2Centers for Disease Control and Prevention, Atlanta GA USA 3Western Kentucky University, Department of Public Health, Bowling Green KY USA

Objective To formally evaluate existing, printed human papillomavirus (HPV) educational materials to determine (1) readability, (2) suitability, and (3) HPV content for women who have HPV or are at risk for HPV.

Background HPV is a common sexually transmitted infection Most women do not know they have high-risk HPV Abnormal Pap test and then HPV DNA test HPV is complex Test positive and then “clear” infection No critical evaluation of HPV educational materials has been published CDC estimates about 5 million men and women acquire a genital HPV infection each year High-risk types – higher risk for cervical cancer Low-risk types – visible genital warts Persistent HPV infection is greatest concern for progression to cervical cancer Immune system can “clear” infection Important information that women need to know…complexities of HPV may not be able to be explained during brief patient-provider encounter, so supplementary materials are important for women to have access to reliable and appropriate information

Methods 21 HPV educational materials were identified for evaluation Content of educational materials included STD, abnormal Pap, cervical health materials that discussed HPV Sources of educational materials: American Academy of Family Physicians (AAFP), American College of Obstetricians and Gynecologists (ACOG), American Social Health Association (ASHA), American Society for Colposcopy and Cervical Pathology (ASCCP), Channing Bete, Digene Corporation, ETR, Krames, National HPV & Cervical Cancer Campaign, Navy Environmental Health Center, Planned Parenthood, Kaiser Family Foundation, National Cancer Institute, SC Dept. of Health and Environmental Control

Methods Three independent evaluators Familiar with HPV and tenets of designing health messages and materials development Scores from three evaluators were averaged Readability assessment Suitability Assessment of Materials (SAM) HPV content assessment

Methods Readability Assessment SMOG (Simplified Measure of Gobbledygoop) Formula to assess reading grade level of a written sample Fry formula Preferred method of Doak, Doak, & Root (1996)

Methods Suitability Assessment of Materials (SAM) Doak, Doak, & Root (1996) Structured approach to evaluating materials Each item is scored 2 = Superior, 1 = Adequate, 0 = Not suitable, NA = Not Applicable Scored items are totaled and divided by total possible (excluding NAs) SAM Rating 70-100% Superior material 40-69% Adequate material 0-39% Not suitable material Total scores for three reviewers were averaged

Methods Suitability Assessment of Materials Content Literacy Demand Purpose Behavioral content Scope Review Literacy Demand Reading grade level Writing style Vocabulary Graphics Explanations Layout and Typography Subheadings Learning Stimulation/ Motivation Interaction Modeled behaviors Motivation Cultural Appropriateness Cultural images and examples

Methods HPV Content Assessment 12 important educational messages were identified Selected materials were reviewed for inclusion of this information and explanation Each of the 12 messages was scored 3 = Adequately explains, 2 = Somewhat explains, 1 = Does not explain, 0 = Information not included in brochure Total score divided by 36 Total scores for three reviewers were averaged

Methods Content Assessment Messages HPV is sexually transmitted HPV is a virus HPV is common Two types: high-risk and low-risk HPV may cause cervical cancer HPV causes genital warts HPV may cause abnormal Pap test HPV may affect pregnancy HPV treatment HPV is spread via skin-to-skin contact Condoms do not always prevent Important to have regular Pap tests

Results: Readability Grade Level SMOG FRY AVE <7 6 1 8 3 4 9 10 2 6 1 8 3 4 9 10 2 11 12 13 14 15 >16 n=21 Range: SMOG 8-16 FRY 5-17 Ave 7-17

Results: Suitability SAM scores Mean: 28% (Not suitable) 40-69% = Adequate 70-100% = Superior Mean: 28% (Not suitable) Range: 14 - 49% Not Suitable Adequate Superior 15 6

Results: Suitability Content Literacy demands Graphics Lacked clear purpose Too limited or too broad of scope Lack of summary to reinforce important messages Literacy demands “Medical terms” often used and not explained Graphics Seemed out of place or irrelevant Did not add to the material These are some of the reasons, in general, why a material scored low on these items.

Results: Suitability Layout Learning Stimulation / Motivation Detracted from messages Overall design not appealing Learning Stimulation / Motivation Lack of focus on behavior Limited interaction Cultural Appropriateness Not addressed in majority Lack of cultural images and examples

Results: HPV Content 12 important messages Mean: 63% Range: 32 – 93% Absent or not well explained messages Two types of HPV: High-risk and Low-risk Treat signs and symptoms not virus May affect pregnancy Transmission skin-to-skin contact Condoms not always effective

Results SAM Score Not Suitable Adequate Superior Number of Materials 15 6 Average Readability 12th 8th N/A Ave. Readability Range 6th – 17th 5th – 10th Ave. HPV Content Score 69% 46% Increasing scores on HPV content assessment were at the expense of readability in some cases

Results Publications scored as “adequate” American Social Health Association A Practical Guide for the Tongue-Tied: How to talk with your health care provider about HPV and STDs Channing Bete Genital Warts and HPV: What you need to know Krames HPV and Genital Warts HPV: Understanding this common virus American Academy of Family Physicians Pap Smears: What they are and what the results mean STDs: Common symptoms and tips on prevention ASHA: Ave RL 8.5, SAM 46%, Content 60% Channing Bete: Ave RL 7, SAM 44%, Content 46% Krames (1): Ave RL 7.5, SAM 49%, Content 65% Krames (2): Ave RL 8, SAM 41%, Content 40% AAFP (1); Ave RL 8, SAM 40%, Content 32% AAFP (2): Ave RL 9, SAM 43%, Content 35%

Discussion Reading levels were too high Design not appealing Limited focus on behavior Increased HPV content = Decreased readability Lack of summary “Generic” information could be confusing

Recommendations Improvements to HPV educational materials are needed to improve readability, suitability, and HPV content Active involvement of target audience Enhance cultural diversity and relevance Women need access to materials that are appropriate and accurate with clear, simple language

Acknowledgment This project was supported under a cooperative agreement from the Centers for Disease Control and Prevention (CDC) through the Association of Schools of Public Health (ASPH). Grant Number U36/CCU300430-22. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of CDC or ASPH.