Analysis of Reader Verification Interviews
Beginnings Parent's Guide Original Edition 2001
Sandra Smith, MPH CHES

New Mexico Department of Health conducted RVIs - Reader Verification Interviews - on Beginnings Parent's Guide booklet #1 during September-October 2000. Maternal-child health care coordinators conducted structured face-to-face interviews according to a protocol at several clinic locations. The interview questionnaire included 36 open-ended questions plus demographic questions. Participants were invited to read sections of the text booklet before the interview and to refer to it during the interview. Interviewers were instructed to record the interviewee's exact words and to avoid offering any encouragement or teaching.

Participants were a convenience sample of women of childbearing age who were residents of New Mexico and visited a DOH clinic during the study period. In recognition of her contribution, each participant was offered a copy of the finished materials and a "Mommy and me" magnetic picture frame valued at approximately $5.

Beginnings Guides, available in English & Spanish, are easy-to-read. To learn more about readability and its value in multi-cultural healthcare, read this article by Sandra Smith & Virginia Gonzales:
Developing Culturally and Linguistically Appropriate Health Education Materials - Studies in Communication Science:5 (2) 111-128 Dec 2005

Core Findings

Preferred format
Interviewers presented each participant 2 prototypes of the test booklet; one 8.5x11" with enlarged type (14pt) and ample white space; and one 5.5x8.5" in the same layout with less white space and 12pt type. While 31% said the large size is easier to read, participants favored the smaller format by a margin of 2 to 1. They said the smaller booklet looks or feels easier to read - it is less daunting, less bulky, looks shorter or smaller, does not look like homework , and is easier to handle, locate and carry.

Education level appears to have little or no affect on preference. The tester with the lowest education level preferred the small size. Three of four with some college also preferred the small size. These results do not support the conventional wisdom that low-skilled (Medicaid-eligible) readers prefer larger type and more white space than other readers, or that larger type and extra white space make materials appear easier to read.

Purpose of the materials
It is essential that readers readily understand the intended purpose of information. If they do not clearly perceive the purpose, they are likely to miss the main points. All participants correctly stated the purpose of the Parent's Guide to inform readers about infant care or parenting. When asked, over ¾ elaborated that the test booklet addresses self-care, parent as teacher, safety and health/healthcare topics. These findings suggest that testers readily understood the purpose of the materials

Attraction
In order for material to have any affect, the intended learner must be moved to pick it up and read it. 92.3% said they would want to read the test booklet. 7.7% said they might read it. 46% said specifically that a picture or color on the cover would attract them. An equal number said they want to learn about parenting - the information itself would attract them. These findings suggest the material is attractive to the intended audience.

Understanding of terms
Provider
23% interpret provider as doctor; 15% interpret provider as a social worker or nurse; 62% apply the general meaning of provider as "someone who takes care of the family" or "makes sure needs of another are taken care of"

When used to refer to health care providers in various specialties, provider is jargon. The majority of women in this sample do not interpret the term provider in a medical or healthcare context. When asked "when your baby is sick and needs medical care, who do you call or take the baby to see?", 85% said doctor; 7.8% said nurse; 7.7% said clinic. These results suggest that the term doctor is more informative than provider.

Caregiver
62% interpret caregiver as a non-medical care provider; 38.5 interpret caregiver more specifically as a babysitter. The term caregiver is suitable as used in the test booklet.

Lukewarm, sibling, checklist, skill, checkup
Participants demonstrated good understanding of these terms. Only one tester (age 15, 6-8 years schooling, ESL) did not articulate a definition of lukewarm or skill.

Keys to a healthy baby
All participants named 2 to 7 things a mother can do to keep her baby healthy, demonstrating good comprehension. Two testers named keep the baby dressed, advice that is not included in the material, demonstrating prior knowledge. Two women, both nulliparous (parity 0), refer to the baby as it.

Most difficult actions
23% said none of the keys to a healthy baby was difficult for them; 23% said trust your instincts was most difficult; 23% said breastfeeding; 15% said learning the baby's cries; 15% said using a car seat; 7.8% said diapering; 7.8% said responding to the baby.

The wide range of perceived difficult actions is notable. This suggests that asking mothers directly how difficult they think it will be to follow advice can produce useful guidance for care coordinators and patient educators regarding the focus of teaching and key messages to be reinforced.

Self-efficacy
Demonstrating high self-efficacy, all but one participant (92.3%) said they would do for their babies the action that is most difficult for them. The exception is a 17-year old unwilling to breastfeed.

Comprehension and persuasiveness of instruction
Teaching your baby: 100% of participants correctly stated that this section asks the reader, in one mother's words, to listen and watch your baby because everything he does is learning and the parent is the best teacher. All said that people they know would follow the instructions, although one was not sure. These results suggest this information is well comprehended and persuasive.

Soothing your crying baby: 100% named several things the baby might be trying to tell you by crying and two or more things they might do to comfort the baby.

Usefulness of summary page on crying: Crying Signals and Soothers
When asked how they might use this page, all testers indicated they would use it as a guide, checklist, reference, or to help figure it out. Responses to this question support findings in the literature that review and summary are helpful to all readers, particularly those with low literacy skills.

Acceptability of information specifically for partners: A Note to Partners
It is noteworthy that while over ¾ of participants are single, 100% freely discuss their partners and 92.3% said they would have their partner read the note. One (age 21, in college, parity 0) said she would not; she thought he would be insulted. One other tester (age 20, in college, parity 0) felt her partner would be defensive. Another (age 15, 6-8 years schooling in Mexico, parity 1) says her partner would be confused. The majority - 69% - thought their partners would respond positively and may be motivated to understand or help more. The note was revised to eliminate a phrase that may have been problematic for some readers.

Checkups and shots
The author and some expert reviewers were concerned that the intended audience might have difficulty reading and understanding the standard immunization schedule. A decision was made to focus on scheduled well-baby checkups, rather than on immunizations. To see if omitting the immunization schedule and reference to it would have any negative affect on parents' understanding of the importance of immunizations or their intention to obtain immunizations for their children, we asked mothers about this section of text.

All testers demonstrated clear understanding of what this section asks them to do. 100% said they would take their babies to checkups and that their friends would be sure to have their babies immunized. These responses demonstrate good comprehension, persuasiveness, and self-efficacy regarding immunizations without reference to the schedule.

Home Safety Checklist
All but one tester named several things that could be done to make a home baby-safe, and named several actions she would take. 62% said they would take all the suggested action steps. The exception (age 15, 6-8 years education, ESL) did not name any action steps answering only "I don't know." However, she said she would take the fire safety measures. These responses demonstrate good comprehension, persuasiveness, and self-efficacy regarding home safety.

Warning Signs
All participants correctly named several warning signs of infant illness warranting medical attention. None added any unlisted signs from prior knowledge or beliefs. When asked what would she do if her baby seemed sick but she was uncertain, 54% said they would call the doctor according to the instruction. 23% said they would take the baby's temperature. 7.7% would take the baby to the clinic rather than calling. 15% said they would call Mom; if the grandmothers said to call the doctor, they would do so.

These responses show good comprehension of the warning signs. Nearly half indicated interim steps (take temp, call Mom) they would take before following the instruction to call the doctor (nurse or clinic). Temperature taking is an appropriate step. It is important to note the influence of grandmothers in this population and their potential as reinforcers of (or barriers to) key messages.

Acceptability
85% found nothing offensive in the materials. As previously noted, one found the Note to Partners insulting; another suggested that it be reformatted like the rest of the text rather than as a letter. None of the participants found anything that they would take out to shorten the text. All said they want to receive the rest of the series. The following testers' comments demonstrate what makes the test material useful for these mothers and how they might use materials to fill gaps in knowledge and promote family health.

• All sections are short and direct, relevant. I like the lists.
• The short blocks are good instead of long explanations
• It would help one to see what I should be looking for - what I should be teaching my kids.
• … Because they are interesting and give you a wide view of what happens to the baby, what to look for, and just the education it gives you
• … Succinctly lists things you should know, especially 1st time mom
• I think they are real informative. If you have any questions, it would be something to try before calling the doctor.
• 'Cause they are informative … short and to the point
• 'Cause I think they are helpful and they can teach you a lot

Note to readers: If you would like to conduct Reader Verification Interviews to learn how your population responds to the Beginnings Parent’s Guide or to the Beginnings Pregnancy Guide, the publisher will provide you a copy of the protocols used in this study. Send email to sandras@beginningsguides.net. For more on Reader Verification Interviews, see Doak, LG, Doak C, Root J. Teaching Patients with Low Literacy Skills 2nd edition, Lippincott, Philadelphia 1996

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