G u i d e l i n e s f o r E f f e c t i v e P r i n t C o

G u i d e l i n e s f o r E f f e c t i v e P r i n t C o m m u n i c
a t i o n
A Guide to Creating and Evaluating Patient Materials
Sincerely,
Deborah Deatrick, MPH
Vice President of Community Health
Jeff Aalberg, MD
Senior Medical Director, PHO
Jackie Cawley, DO
Senior Medical Director, MaineHealth
Dear Colleagues:
MaineHealth’s aim to provide the best possible care for our
patients and communities requires effective
health communication. As our population ages and diversifies,
and as medicine and self-care grow ever
more complex, the ways in which we communicate become even
more important. This guide is a tool
for all MaineHealth member and affiliate organizations to
communicate clearly and consistently with
patients and families.
Supports our goals. Effective communication to our patients and
community members supports

MaineHealth goals to:
■ Promote patient understanding and ability to adhere to
prevention, treatment and care plans
■ Provide safe, effective, quality care
■ Streamline care
■ Meet new Joint Commission accreditation guidelines
Reflects evidence and best practice. The Checklist to Develop
and Evaluate Patient Education
Materials and the guidelines that follow are evidence-based and
reflect best practice. Many of our
patients have limited literacy and health literacy skills. They
require easy-to-understand information.
All adults, when sick or stressed, need clear, accessible
information. And almost all adults prefer it.
No one wants to struggle to grasp instructions critical to his or
her well-being.
Addresses national priorities. These guidelines also reflect
recommendations of national medical,
public health, research and policy groups including the Institute
of Medicine, the American Medical
Association, the Centers for Disease Control and Prevention,
the Agency for Healthcare Research and
Quality, and The Joint Commission.
Guidelines are only as effective as their implementation. We
will help you learn how to use them.
MaineHealth Learning Resource Center staff provide training
and consulting in developing patient-
friendly print materials. Contact them for help with your next
patient materials project.

Thank you for your leadership and commitment to providing the
best patient care possible and for
helping to implement this guide in your organization.
G u i d e l i n e s f o r E f f e c t i v e P r i n t C o m m u n i c
a t i o n
Why is this important?
Table of Contents
Key Facts About Health Literacy 1
Developing Patient Education Materials: A Step-by-Step
Approach 3
Checklist to Develop and Evaluate Patient Education Materials
4
■ Key Elements 1 and 2: Content and Structure/Organization 5
■ Key Element 3: Writing Style 7
■ Key Element 4: Appeal/Document Design 9
■ Key Element 5: Cultural Sensitivity and Appropriateness 11
Readability 12
■ What Is Readability? 12
■ Readability in Word Processing Programs 12
Checklist Worksheet 13

Additional Resources 16
Guidelines for Effective
Print Communication
Key Facts About Health Literacy
Literacy and health literacy affects all Americans.
■ Literacy: The ability to read, write, compute,
understand and use written information.
Even adults with adequate literacy skill may struggle with
health literacy.
■ Health literacy: The ability to use complex literacy
skills in health-related circumstances
and environments to help prevent, manage and treat health
conditions.
■ Health literacy as a policy issue reflects the mismatch
between the limited literacy skills
and understanding of health context that adults “bring to the
table” and the high levels
at which health professionals usually communicate. Average
reading level for working adults
is about grade level 7/8. Elders and other vulnerable
population groups demonstrate even
more limited skills. “Yet, most health information is delivered
at a high school level or
above - far beyond adult abilities.” Well-educated adults
prefer easy-to-read information.
They don’t want to struggle to understand.

Results of the 2003 National Assessment of Adult Literacy
showed
that only 12 percent of American adults have proficient health
literacy
skills.
■ Nearly half of American adults lack adequate literacy
skills. More than half lack adequate
numeracy skills to function effectively in our information-
dependent culture.
■ The most vulnerable populations have the most limited
literacy skills: elders, Hispanics/
Latinos, immigrants, the poor and adults with chronic health
conditions.
■ Groups with limited literacy skills have poor health.
Research has shown lower
adherence to medication and treatment plans, reduced levels of
prevention, and increased
hospitalizations and deaths.
1
Key Facts About Health Literacy
Key Facts About Health Literacy Evidence supports 2 major
solutions | Teach-back and plain language
■ Teach-back in verbal communication improves patient
understanding and outcomes.
■ Plain language in all forms of communication - print,
verbal, electronic, media - increases
understanding and patient adherence to instructions.

■ Plain language is more than short words. It means using
proven techniques to plan,
structure, write and design clear, accessible information.
“Dumbing down” information is a myth - one of many.
■ Adults prefer easy-to-use information, especially when
they are stressed or hurried.
■ Plain language is legal and is supported by the
American Bar Association.
■ Plain language is savvy business. It protects
organizations and satisfies customers.
As our patient population ages and diversifies, the need to
understand health
literacy and respond with effective communication strategies
will increase.
■ Maine has one of the fastest-aging populations in the
country and is growing
more diverse.
■ Effective communication addresses patients’ needs,
Joint Commission requirements,
patient safety and patient-centered care goals, and business
realities.
■ All departments can use the materials guidelines and
supporting documentation to help
achieve a common goal: communication excellence.
2

P L A N N I N G
1 . Determine the purpose. List the behaviors or actions you
expect your audience to take. Write down
what they need to know to take those actions.
2 . Identify key players and those with a vested interest in the
material. Consider who should
contribute: content expert, legal adviser, clinician, health
educator, care manager, marketing/
community relations, program managers and patient advisors.
3 . Identify the audience. Think carefully about whom you are tr
ying to reach. Consider: W hat does
the audience know? W hat skills do they need? W hat are their
concerns? This is the time to talk
with members of your target audience to learn more about them.
4 . Don’t reinvent the wheel. Check to see if the materials you
need have already been developed
within the MaineHealth system or beyond.
5 . Think about how your educational piece will be designed,
printed and distributed.
6 . Develop a timeline for the project.
D E V E L O P M E N T / D E S I G N / T E S T I N G
7 . Develop and write the material, using these guidelines.
8 . Obtain feedback from clinicians and other members as
appropriate to validate the accuracy of the
clinical content.

9 . Consult with the marketing/community relations department
about the material ’s design.
1 0 . Test your material ’s with consumers. Validate that it ’s
meeting the goals you had in mind.
Revise as needed.
R E V I E W A N D A P P R O VA L
1 1 . Developer(s) will submit the material to the appropriate
workgroup or committee for review and
recommendations along with a brief statement of the piece’s
purpose, the audience and the testing
that has been done.
1 2 . Send material to your marketing/community relations
department for review and proofreading. For
larger booklets, you may want to consider contracting with an
outside proofreader to review the
full document. Contact the marketing/community relations
department for more information.
Developing Patient
Education Materials
A Step-by-Step Approach
3
A Step-by-Step Approach
Checklist
Issue 1: Audience is clear. Audience is
_________________________________________

Issue 2: Purpose is clear. Purpose is
___________________________________________
Issue 3: Patient/consumer testing planned
______________________________________
Key Element 1: Content
❏ Limited (three to five points) and action-focused (what to
do/need to know)
❏ Accurate, evidence-based and up to date
❏ Framed to gain positive audience response
❏ Includes clear call to action as appropriate
Key Element 2: Structure/Organization
❏ Content broken into small chunks with important points first
❏ Subtitles/headings are statements, questions or action phrases
that guide the reader
❏ Content sequenced according to reader need to know
❏ Key points are repeated as appropriate
Key Element 3: Writing Style
❏ Personal, conversational (use pronouns appropriately and
consistently)
❏ Short words/short sentences/lay language; technical terms
explained
❏ Mostly active voice; verbs carry the action
❏ Short paragraphs (about three to five sentences) that stick to
one point
❏ Short lists (about three to five items) using bullets, not
comma strings
Key Element 4: Appeal/Document Design

❏ Piece attracts attention/draws reader in
❏ Text design makes it easy to skim and scan content
❏ Overall design reflects plain language standards for font type
and size, print/paper contrast,
line length, white space, justification
❏ Images, lists, charts are clear/support message/reflect
audience
Key Element 5: Cultural Sensitivity and Appropriateness
(As applicable, reflects needs and values of cultural groups
defined by ability/disability, gender
orientation, race/ethnicity, socio-economic status, etc.)
❏ Uses preferred and respectful terms to refer to the group or
condition, and focuses on the person
Example: “a person or patient with diabetes” instead of “the
diabetic”
❏ Considers ease of potential translation/transadaptation if
applicable
❏ Reflects group understanding of health/illness and role of
medical care
❏ Considers use of complementary medicine or other practices
❏ Reflects expected roles of individual, family and cl inician in
medical decisions
Checklist Worksheet can be found on Page 13.
4
Limit content. Organize and structure to guide readers.
Adults can read, remember and use only three to five key points
at one time. If understanding a

health condition or instruction requires more points, group or
chunk them into sections that can
be read over time. Double-check that information is accurate,
evidence-based and up to date.
Plan with the end in mind - usually action. What behavior or
action do you want the reader to
carry out? Learn about your audience, and plan materials to
address their needs, concerns, beliefs
and skills.
■ Consider:
❏ What does the audience already know? What do
they want to know more about?
❏ How does the audience feel, think and behave
with regard to the actions we recommend?
What skills do they have, and what skills might they need to
learn?
❏ What kinds of messages and tone are likely to
connect with the audience?
Example: A flu poster at the homeless shelter reads, “Stay
home if you are sick.”
This message is offensive, not supportive.
■ Create information structure and flow that reflect
audience priorities and needs.
❏ Present the most important information first.
Get to the point quickly.
❏ Stick to three to five major points. Most people
can read and remember only this many

at any given time. Many will read only the first few.
❏ Web users skim and scan for just the
information they want. Make it easy to find!
❏ Avoid the medical model of information
sharing, which starts by explaining the clinical
diagnosis and/or human anatomy. Instead, use a patient-
centered model that focuses first
on the problem and the solution – what to do and how to do it.
Details about the
anatomy and pathophysiology of a condition may be of
interest later, after readers
understand the basics.
Key Elements 1 and 2
Content and Structure/Organization
5
Content and Structure /Organization
Example of two different ways to introduce blood pressure
control:
Less effective (medical model): “Blood pressure is the force of
the blood against the walls of the arteries.
The heart generates this pressure by contracting 60 to 90 times
per minute, circulating blood to all parts
of the body …”
More effective (patient-centered model): “High blood pressure:
You can do something about it. If your

blood pressure stays too high, you run the risk of having a
stroke, heart attack or kidney problems …”
■ Present information in small chunks.
❏ Keep paragraphs short and limited to one idea.
❏ State the main message in the first sentence.
❏ On the Web, be especially brief. Bulleted lists work well.
■ Use subtitles to carry major messages or ask key questions.
❏ Use statements, action phrases or questions as subtitles.
Subtitles tell the story.
Example:
Less effective subtitle: “Hygiene”
More effective statement subtitle: “Keep your skin clean to
prevent infection.”
❏ Questions can be effective subtitles but only if they are
questions the audience is likely to
ask and that are important to them.
Example:
Less effective question subtitle: “What does diabetes mean for
cardiovascular health?”
More effective question subtitle: “Will diabetes affect my
heart?”
■ Repeat key points as appropriate and in different ways.

❏ One way to repeat important information and
create reader interaction, is by using
creative techniques like testimonials, miniquizzes, check
boxes to complete, rhetorical
questions, etc. Powerful images with strong captions can also
reinforce messages.
❏ When phone numbers or other contact
information is important, consider putting it
in more than one place, even on a single-page handout. When
patients need to use
contact information, they may be stressed and need to find it
in a hurry.
6
Write in plain language to make reading easier and more
understandable.
■ Use short, everyday words and short sentences. Use as
few medical and biological terms
as possible. Keep your writing tight and specific, but not to
the point of being choppy.
Instead of … Use …
Hypertension High blood pressure
Oncology Cancer
Hospitalization Stay in the hospital

Hypoglycemia Low blood sugar
❏ Average sentence length should be around 15
words for reading ease.
Some sentences can be a little longer, some a little shorter.
Cut out
unnecessary words and phrases like “It is important to …”
Keep your
writing tight. In general, plain language writing style relies on
strong nouns
and verbs. Use modifiers such adjectives, adverbs and clauses
with caution.
❏ State desired behaviors explicitly. General
concepts don’t lead to action.
Example:
Original: “The Dietary Guidelines for Americans recommends
a half hour or more of
moderate physical activity on most days, preferably every day.
The activity can include
brisk walking, calisthenics, home care, gardening, moderate
sports exercise and dancing.”
Rewrite: “Do at least 30 minutes of exercise, like brisk
walking, most days of the week.”
Key Element 3
Writing Style
7

Key Element 3
Writing Style
■ Use active voice. This means the subject of the sentence
performs the action. Look for the
passive voice when a form of the verb “to be” is used. Here’s
the list: am, are, is, was, were, be,
been, being. These words are usually followed by a helping
word.
Example:
Passive: Patients are advised to bring their insurance cards to
every visit.
Active: Bring your insurance card to every visit.
■ Be personal, conversational, human. Use pronouns when
appropriate. Pretend you’re
talking with a neighbor or family member. Write it as you’d
say it. Use brief examples
to model how to take the actions you recommend. Testimonials
and vignettes also
create connection.
Example of a patient testimonial:
“When my doctor first told me I had diabetes, I was shocked.
After that, I didn’t remember
anything she said. I was really glad the diabetes educator called
the next day to see if I
had questions.”
Example of personal vs. impersonal:
Impersonal: MaineHealth offers patients evidence-based care.

Personal: We offer you care based on the latest research.
■ Keep paragraphs and lists short.
❏ Keep each paragraph focused on one major
point, using about three to five sentences.
The first sentence (lead) gives the major point. Establish a
“flow” within and between
paragraphs.
❏ Ideal length for lists is about three to five
points, sometimes up to seven. Do not embed
lists in text using commas. Instead, itemize lists using bullets
and be sure to title the list.
Readers do not always read explanations before they read
lists, so the title must tell them
what it is.
8
Design for reading ease and understanding “on the first read.”
Create clean, functional design in print and on the Web.
Materials are not intended to be artwork, yet
they should still engage and invite. Information that looks easy
to read is most likely to get attention.
This means designing text with a clear visual structure that
makes it easy for a reader to skim, scan
and get major points fast. Refer to your
marketing/communications department for organizational
brand standards.

■ Usually, simple is best. This doesn’t mean dull. It
means clean and functional.
❏ Certain styles in text layout and graphics – such
as titles and sentences all in lowercase
and right-justified or title words “scrambled” in different
fonts – do not support
reading ease.
❏ Straightforward visual design helps the user see
the information structure right away.
■ Use text features that increase reading speed and
comprehension.
❏ Font size: Optimal font size for fast print
reading is 11 - 14 points. Usually, older readers
prefer larger print. Font size on the Web should be adjustable.
❏ Font style: Use all capital letters, stylized font
or italics with caution. They slow down reading.
❏ White space: Adequate white (blank) space
creates text structure and allows the eye to
both see and “rest between” sections and pages. If space is
limited, better to sacrifice text
than white space.
❏ Justification: General rule for text margins is
left justify, right ragged, with no text
“wrapping” around pictures.
❏ Line length: Optimal is three to five inches.
Shorter and longer lines slow reading speed and
reduce comprehension.

Key Element 4
Appeal / Document Design
9
Key Element 4
Appeal / Document Design
❏ Hyphenation: Do not split (hyphenate) words
between lines.
❏ Ghosting: Do not superimpose print over
pictures or other graphic elements.
❏ Creating emphasis: Use color, bolding, boxes,
arrows and other visual devices with
discretion, to call attention to key points.
■ Use images and other graphic elements to support the
text, not decorate it.
❏ Print-paper contrast: Keep print dark and paper
light, especially for older eyes.
Reverse print (light print on dark background) can work in
small quantities,
such as for titles.
❏ Color: Save colored text mostly for titles or
subtitles. Use color for images and design
features with care – to enhance key points, information
structure and appeal.

❏ Images: Images may support the text directly or
indirectly. They work best when simple
and uncluttered so readers understand them at a glance. Use
captions to strengthen major
points. When using images to teach, show the “right way.” If
you must show a wrong
action, put a big X through it (not a circle with a line).
❏ Cultural inclusiveness: Images should reflect
cultural sensitivity and inclusion.
❏ Lists and charts: Keep lists short, preferably
three to five items. Use subtitles to group
the items and bullets for the list. Keep charts simple and
designed for “reading across.”
For a grid or matrix, limit items and give directions for use.
❏ Explaining risk: Use frequencies (numbers), not
percentages.
Easiest to understand: x out of 10, or out of 100, or out of
1,000. In addition, for risks
with a denominator of 100 or 1,000, best practice is to use
pictograms along with
numbers. Pictograms are organized groupings of small dots or
squares that allow a reader
to see an entire cohort (of 100 or 1,000). Dots or squares that
represent the number of
people at risk are colored to stand out.
■ Don’t miss the chance to include a key message on a
cover
or home page.
❏ Covers and home pages are prime “real estate.”
Imagine your audience reading only the front and back

covers of a print piece or only the home page. Did they get
some key information? They might not read further.
1 0
Plan, write and design materials to reflect the audience and be
as inclusive as possible.
Culture is a broad concept that goes way beyond ethnicity or
country of origin. It includes
ability/disability, gender orientation, race/ethnicity, socio-
economic status and other critical
life-shaping forces.
Culture shapes understandings about the meaning of illness,
appropriate care-seeking and care
providers, prevention and treatment practices, health decision-
making, and more. Understanding
cultural diversity and the beliefs and practices of our patients
helps inform how to communicate.
Incorporating cultural understanding with plain language will
also create translation ease.
■ Our patients are growing older and more diverse,
reflecting national
population trends.
❏ American populations growing most rapidly
include seniors and Hispanic/Latino groups.
❏ These same populations carry a disproportionate
burden of diseases and
health conditions.

❏ Nearly two-thirds of the adults in these groups have
basic or below-basic levels of literacy
and health literacy skills. Many do not speak English as their
primary language.
■ Plain language works across cultures to address
cultural, linguistic and functional
challenges.
❏ Plan message design and images that reflect the
diversity of patients who will use
your materials.
❏ Use respectful language. Speak about “patients
with asthma” instead of “asthmatics.”
❏ Consider visual needs and possible functional
impairments. At a minimum, use adequate
font size, maintain contrast between text and background, and
consider Web navigation
challenges as appropriate.
Key Element 5
Cultural Sensitivity and Appropriateness
1 1
Key Element 5
Cultural Sensitivity and Appropriateness
Readability
What Is R e a d a b i l i t y ?
Has anyone ever said to you, “All our materials have to be

written at the sixth-grade level”?
What does that really mean?
Grade levels are derived from readability formulas, which are
mathematical formulas used to
produce a numerical score. The score shows the relative
difficulty of text on a continuum from
easy (grade four to six) to very hard (grade 13 and above –
college level). “The average reading
ability of American adults is about seventh- to eighth-grade
level.”
A readability score is given as a “grade level,” but a score
doesn’t tell us whether an adult with
a specific level of education will be able to read the text. There
is no direct correspondence
between an individual’s level of education and his or her ability
to read a particular piece of text.
For example, most high school graduates cannot read at the
12th-grade level. Readability scores
are best used to assess whether your text is in the right “ball
park” for your intended audience.
In general, this means that material should be at an eighth-grade
level or below for public
audiences.
Readability in Word Processing Programs
You may have discovered that popular word processing
programs like Microsoft Word have
readability functions such as the Flesch Reading Ease and the
Flesch-Kincaid Grade Level.
The results are not accurate.
Here’s the key point: If you follow these guidelines for writing
in plain language, using shorter
and nontechnical words and shorter sentences, you will likely

write at a readability level
appropriate for most patients.
The Learning Resource Center can provide a readability score
for your material.
If you would like to have your print material “scored” for
readability level, contact the Learning
Resource Center. We have a special software program that can
provide results, or we can teach
you how to calculate a readability score by hand.
H a v e q u e s t i o n s o r n e e d h e l p ? C a l l t h e
L e a r n i n g R e s o u r c e C e n t e r a t 8 6 6 - 6 0 9 - 5 1
8 3
o r v i s i t w w w. m a i n e h e a l t h . o r g / h e a l t h l i t e
r a c y
1 2
Issue 1: Audience is clear. Audience is
_________________________________________
Issue 2: Purpose is clear. Purpose is
___________________________________________
Issue 3: Patient/consumer testing planned
______________________________________
Key Element 1: Content
❏ Limited (three to five points) and action-focused (what to
do/need to know)
❏ Accurate, evidence-based and up to date

❏ Framed to gain positive audience response
❏ Includes clear call to action as appropriate
Other Comments
_____________________________________________________
___________________
_____________________________________________________
___________________
_____________________________________________________
___________________
Key Element 2: Structure/Organization
❏ Content broken into small chunks with important points first
❏ Subtitles/headings are statements, questions or action phrases
that guide the reader
❏ Content sequenced according to reader need to know
❏ Key points are repeated as appropriate
Other Comments
_____________________________________________________
___________________
_____________________________________________________
___________________
_____________________________________________________
___________________
Key Element 3: Writing Style
❏ Personal, conversational (use pronouns appropriately and
consistently)
❏ Short words/short sentences/lay language; technical terms

explained
❏ Mostly active voice; verbs carry the action
❏ Short paragraphs (about three to five sentences) that stick to
one point
❏ Short lists (about three to five items) using bullets, not
comma strings
Other Comments
_____________________________________________________
___________________
_____________________________________________________
___________________
_____________________________________________________
___________________
1 3
Checklist Worksheet
Key Element 4: Appeal/Document Design
❏ Piece attracts attention/draws reader in
❏ Text design makes it easy to skim and scan content
❏ Overall design reflects plain language standards for font type
and size,
print/paper contrast, line length, white space, justification
❏ Images, lists, charts are clear/support message/reflect
audience
Other Comments
_____________________________________________________
___________________

_____________________________________________________
___________________
_____________________________________________________
___________________
Key Element 5: Cultural Sensitivity and Appropriateness
(As applicable, reflects needs and values of cultural groups
defined by ability/disability, gender
orientation, race/ethnicity, socio-economic status, etc.)
❏ Uses preferred and respectful terms to refer to the group or
condition,
and focuses on the person
Example: “a person or patient with diabetes” instead of “the
diabetic”
❏ Considers ease of potential translation/transadaptation if
applicable
❏ Reflects group understanding of health/illness and role of
medical care
❏ Considers use of complementary medicine or other practices
❏ Reflects expected roles of individual, family and clinician in
medical decisions
Other Comments
_____________________________________________________
___________________
_____________________________________________________
___________________
_____________________________________________________
___________________
1 4

Notes:
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_____________________________________________________
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_____________________________________________________
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_____________________________________________________

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_____________________________________________________
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_____________________________________________________
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_____________________________________________________
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1 5
Copyright December 2010 by MaineHealth. All rights reserved.
The material contained in this publication may be displayed,
copied,
distributed or downloaded for personal or noncommercial uses,
provided that such material is not altered or modified and that a
reference to MaineHealth is provided. Please note that printed
materials are not a substitute for seeing a doctor. Patients
should be
encouraged to discuss printed materials when working with their

providers.
This document may be downloaded as a PDF file from the
MaineHealth website, www.mainehealth.org/healthliteracy.
To request a printed copy or for other inquiries regarding
specific permissions, please contact the
MaineHealth Learning Resource Center at
www.mainehealth.org/lrc or 866-609-5183.
Acknowledgments
MaineHealth would like to acknowledge the dedicated work of
members across the MaineHealth system in developing this
resource.
Additional Resources
For more information, resources and tools on health literacy,
please contact the
Learning Resource Center.
Phone: 866-609-5183
E-mail: [email protected]mainehealth.org
Web: www.mainehealth.org/healthliteracy
Visit the Learning Resource Center’s Health Literacy website at
www.mainehealth.org/healthliteracy for online tools, including:
■ Reports and statistics.
■ Examples of effective patient materials.
■ Online training opportunities.
■ Helpful tools, including a plain-language thesaurus.

Additional Resources
Notes
MaineHealth is a not-for profit family of leading high-quality
providers and other healthcare
organizations working together so our communities are the
healthiest in America.
www.mainehealth.org/healthliteracy
IHP 525 Final Project Article Review Guidelines and Rubric
Overview
There are two final projects in this course. One is an article
review and the other is a data analysis.
Regardless of their field of interest, health professionals across
disciplines need to be able to analyze and use biostatistical data
to address health concerns
among the populations they serve. They need to be able to
identify trends, draw conclusions, and make recommendations
for improving health outcomes based
on solid evidence. It is also important that they are able to
communicate that information effectively to those directly or
indirectly impacted. They also need to
understand what others are doing in their field, the strengths

and limitations of that work, and how it affects their own
organization, even if they do not intend
to become statisticians.
The two summative assessments for this course lay the
foundation for these critical skills. Final Project Article Review
asks you to evaluate the strengths and
limitations of existing biostatistical articles and to identify the
selection process of appropriate methodologies in different
contexts (Final Project Article Review).
You will present your analysis through a written executive
summary geared toward an audience of fellow health
professionals. In the Final Project Data Analysis,
you will calculate descriptive and inferential statistics of a
small data set. You will explain the basic parameters of the
data, graph it, and run simple hypothesis
tests. You will present your analysis in a statistical report
geared toward a non-technical audience, draw conclusions, and
make recommendations for further
research.
For your Final Project Article Review, you will review and
analyze published research that you might encounter as a health
professional. You will select two
journal articles from the provided list on a topic of interest. You
will create an article review that identifies the articles and their
relevance to your field;
summarizes the articles, including their findings; compares and
contrasts the statistical methods used in the articles; explains
why the methods used were
appropriate; discusses their limitations; and concludes with
recommendations for future work.
Final Project Article Review is divided into three journals,
which will be submitted at various points throughout the course
to scaffold learning and ensure quality

final submissions. These article journals will be submitted in
Modules Two, Five, and Six. The completed article review will
be submitted in Module Eight.
In this assignment, you will demonstrate your mastery of the
following course outcomes:
● Analyze the role of biostatistics for its impact on professional
decision making in the public health, nursing, or health science
fields
● Interpret key biostatistical metrics, methods, and data for
addressing population-based health problems
● Evaluate the quality and limitations of published public
health, nursing, and health science research by comparing and
contrasting biostatistical methods
and analysis used to support a variety of health initiatives
● Communicate biostatistical results, procedures, and analysis
to other health professionals and the general public for
informing their decisions related to
population-based health problems
Prompt
Imagine you are a biostatistician working at a local health
organization. Part of your job is to analyze trends and draw
conclusions about health issues that affect
your organization. Your supervisor has asked you to do a quick
literature search for published research on an upcoming topic as
preparation for a new project.
The goal is to understand the current biostatistical methods and

guidelines being used on similar studies so that you could
eventually use that to inform the
design of the new study.
Your job is to find a minimum of two research articles on your
topic from the Final Project Article Review Articles List
document, examine the broad health
question(s) addressed in each, and critically assess the
statistical methods used to analyze the data and arrive at the
articles’ conclusions. You will present the
results of this analysis to your supervisor and peers in an article
review.
Specifically, your article review must address the following
critical elements:
I. Background: Use this section to provide a brief context for
the health problem, issue, or trend you are researching.
Specifically, you should answer:
A. What topic or health question did you research and why is it
relevant to public health, nursing, or the health science
professions? Give real-
world examples to support your answer.
B. How can biostatistics help inform decision making around
your topic? Support your answer with specific examples.
II. Article Selection: In this section, discuss how and why you
selected your main article and the related article. Be sure to:
A. Explain why you selected these specific articles to examine
over others in your field that use biostatistical methods and
data. Justify your
answer.

B. Assess each article’s importance to health decision making in
your field. Give real-world examples to illustrate your answer.
III. Findings: This section should highlight the major findings
of each of the articles you selected for your supervisor and
peers. Specifically:
A. What are the findings of each article and what implications
do they have individually and collectively for solving the health
problem in
question? Support your answer with specific examples from
your field.
B. Explain how key biostatistical calculations and methods
support the conclusions in each article. Cite relevant
information from the articles
that support your answer.
IV. Methods: Use this section to compare and contrast the
methods used in the articles you selected with an eye to
assessing the quality and limitations
of the findings and informing future research. Specifically, you
should:
A. Explain why the authors of each article selected the methods
they did. How appropriate were the methods to the overall
purpose of the
paper? Justify your response.
B. Analyze a difference and similarity in the methods chosen
with respect to the health question being addressed in the
selected articles.
Explain your answer using evidence from the articles selected

and information you have learned in the course.
C. Assess a strength and limitation of the different approaches
used in the articles you selected. Explain your answer using
evidence from the
articles you selected and information you have learned in the
course.
http://snhu-
media.snhu.edu/files/course_repository/graduate/ihp/ihp525/ihp
525_final_project_part_i_articles_list.pdf
V. Conclusions: What does your evaluation of the strengths and
weaknesses of the articles you selected suggest for future
research in this field? Be
sure to provide specific suggestions for potential next steps,
based on evidence from your analysis, and explain how these
suggestions would help
improve decision making.
Journals
The journal activities in this course act as milestones that will
help you prepare for your Final Project Article Review
submission.
Module Two Journal: Article Selection
In Module Two, you will submit a paragraph to select and
explain your articles and health question. This assignment will
be graded using the Journal Rubric.
Module Five Journal: Article Findings

In Module Five, you will explain the findings in the two articles
relating to the health question you identified. This will be
submitted as a table and at least two
paragraphs. This assignment will be graded using the Journal
Rubric.
Module Six Journal: Article Methods
In Module Six, you will complete a table in which you compare
the methods used in the two articles. You will also submit
explain this comparison. This
assignment will be graded using the Journal Rubric.
Final Project Article Review Submission:
In Module Eight, you will submit your Final Project Article
Review. To create this document, revise the journals throughout
the course incorporating the
feedback from your peers and instructor into one final document
that includes all the sections of this article review project. The
final submission will be graded
using the Final Project Article Review Rubric.
Final Project Article Review Rubric
Guidelines for Submission: Your article review should be
approximately 2–4 pages long (not including bibliography),
double-spaced, 12-point Times New Roman
font, with one-inch margins and citations in APA format. Be
sure to use language and a style appropriate to an audience of
knowledgeable health professionals.
Critical Elements Exemplary (100%) Proficient (90%) Needs

Improvement (70%) Not Evident (0%) Value
Background: Topic
Meets “Proficient” criteria and
examples provided establish
clear connections and
relevancy of the topic or health
question
Identifies topic or health
question researched and why it
is relevant, giving real-world
examples to support answer
Identifies topic or health
question and relevance, but
does not give real-world
examples or examples are not
relevant
Does not identify topic or health
question researched and why it is
relevant
10
Background:
Biostatistics
demonstrates keen insight into
the diverse ways biostatistics
can be used to answer health

questions
Analyzes how biostatistics can
help inform decision making
around selected topic,
supporting answer with specific
examples
Analyzes how biostatistics can
inform decision making around
topic, but does not support
with relevant examples or
response contains inaccuracies
Does not analyze how
biostatistics can help inform
decision making around selected
topic
10
Article Selection:
Specific Articles
response considers various
article sources and multiple
aspects of article quality
Explains why specific articles
were selected over others in
field and justifies response
Explains why specific articles
were selected over others in

field and justifies response, but
response contains inaccuracies
or justification is illogical or
irrelevant
Does not explain why specific
articles were selected over others
in field and does not justify
response
10
Article Selection:
Decision Making
examples provided
demonstrate a sophisticated
awareness of each article’s
applicability to a particular field
Assesses each article’s
importance to health decision
making in field, giving real-
world examples to illustrate
answer
Assesses each article’s
making in field, but does not
give relevant real-world
examples to illustrate answer,
or response contains
inaccuracies

Does not assess each article’s
making in field
10
Findings: Implications
examples provided masterfully
demonstrate cogent
connections between field and
article findings
Communicates findings and
implications of articles—
individually and collectively—
for solving health problem in
question, supporting answer
with specific examples from
field
Communicates findings and
implications of articles—
individually and collectively—
for solving health problem in
question, but does not support
with specific examples from
field, or response contains
inaccuracies
Does not communicate findings
and implications of articles—
individually and collectively—for
solving health problem in

question
8
Findings: Biostatistical
Calculations
explanations are particularly
clear and relevant to health
decision makers
Accurately explains how key
biostatistics and methods
support conclusions and cites
relevant information from
articles
Explains how key biostatistics
and methods support
conclusions, but does not cite
relevant information from
articles, or response contains
inaccuracies or omits key
details
Does not explain how key
biostatistics and methods support
conclusions of each article

9
Methods: Why
justification demonstrates a
complex grasp of the authors’
methods and their
appropriateness
Explains why authors of each
article selected methods they
did, including how appropriate
methods were to the purpose
of paper and justifies response
Explains why authors of each
article selected methods they
did, including how appropriate
methods were to the purpose
of paper, and justifies
response, but response
contains inaccuracies or
justification is illogical or
irrelevant
Does not explain why authors of
each article selected the methods
they did, including how
appropriate methods were to
purpose of paper and does not
justify response
10

Methods: Differences
and Similarities
evidence utilized demonstrates
an astute ability to recognize
and illustrate differences and
similarities in methods
Analyzes differences and
similarities in methods used
with respect to health question
addressed, explaining answer
using evidence from articles
selected and information from
class
Analyzes differences and
similarities in methods used
with respect to health
question, explaining answer
using evidence from articles
selected and information from
class, but response contains
inaccuracies, or explanation is
illogical or irrelevant
Does not analyze differences and
similarities in methods used with
respect to health question,
explaining answer using evidence
from articles selected and
information from class

10
Methods: Strengths
and Limitations
evidence utilized demonstrates
an astute ability to recognize
and illustrate strengths and
limitations in approaches
Assesses the strengths and
limitations of different
approaches used, explaining
answer using evidence from
articles selected and
information from class
Assesses the strengths and
approaches used, but does not
explain answer using evidence
from articles selected and
information from class,
response contains inaccuracies,
or explanation is illogical or
irrelevant
Does not assess the strengths and
approaches used
10

Conclusions
uses information and the
suggestions for next steps are
appropriate for healthcare
decision making on a larger
scale than just the populations
represented in the articles
Analyzes what strengths and
weaknesses of articles suggest
for future research, providing
specific suggestions for
potential next steps and
explaining how suggestions
would help improve decision
making, based on evidence
from analysis
Analyzes what strengths and
weaknesses of articles suggest
for future research, providing
specific suggestions for
potential next steps, but does
not explain how suggestions
would help improve decision
making, or suggestions are not
based on evidence from
analysis or response contains

inaccuracies
Does not analyze what strengths
and weaknesses suggest for
future research, providing
specific suggestions for potential
next steps
10
Articulation of
Response
Submission is free of errors
related to citations, grammar,
spelling, syntax, and
organization and is presented
in a professional and easy to
read format
Submission has no major errors
spelling, syntax, or organization
Submission has major errors
that negatively impact
readability and articulation of
main ideas
Submission has critical errors
that prevent understanding of

ideas
3
Total 100%
Caregivers in Healthcare
Maria Williams
Southern New Hampshire University
6/20/2021

Caregivers in healthcare
Background
Because not every caregiver gets positive returns from patients,
this study aims at understanding the various factors associated
with providing care and the expected outcomes. Vascular
nursing and cancer treatments require utmost care and mostly to
the elderly. The distress involved with poor or lack of
movements in these patients necessitates this research
articulation. The cancer spouse caregivers and vascular patients
share the art of protection by the hospital and home care nurses.
The inability of these patients to move at the critical states of
their disease calls for utmost medical and personal attention
from caregivers. From a vascular perspective, the study
investigated the effects of positional change in patients with
acute coronary angiography.
Article Section
I choose these articles because they all entail the aspect of
caregiving in healthcare. Cancer and acute angiography patients
are risky patients that require attention at all times (Valiee et
al., 2016). In this regard, caregivers need supportive and
continuous morale-boosting to their patients. This attitude can
change patients’ perception to get better in the future despite
the adverse conditions they are passing through.
Article 1.
Statistical methods used
This study was a randomized clinical trial. Sixty patients wer e
selected randomly to undergo angiography tests that were
handed to, practitioner. Further, Reblin (2016) examines that 30
cases in each group were used as the general intervention but
patients in the control group remained in bed rest positions. In
the intervals between 3 hourly deviations, patients with vascular
complications were evaluated. Data was analyzed repeatedly by
use of Friedman, Mann-Whitney, chi-square, Kolmogorov tests

by using SPSS in the analysis.
Article 2
Statistical methods used
To this end, Valiee et al (2016) examine the use of descriptive
analysis, independent t, and x-squared tests were used to
compare and contrast the ambivalent and supportive elements in
caregiver relationships. Furthermore, a maximized structural
equation model in MPlus software was used to determine
contexts of relationships in caregivers and patients. The above
models measured the levels of anxiety, depression, and the
mood of the relationship between patients and their caregivers.
Similarities and differences
The first article used many tools in the analysis of their data via
SPSS. The second article used a descriptive model that involved
comparison of supportive and ambivalent relationships between
patients and caregivers. However, both systems of analysis used
the independent t and x-squared models in determining
caregiver and patient responses (Reblin, 2016).
Strengths and limitations
The first article was more elaborate than the second one. From
using close to 5 test methods via SPSS, the second article only
used descriptive analysis that can be biased under certain
observations. However, Reblin (2016) says both articles were
able to provide summative results in their caregiver-patient
relationships. In the first article, there was clarity in
demographic differences, interventional and significant
characteristics. The issue of thrombosis and bruises was
articulated well despite failing to show complete data on
patients with back pain. In the second article, questionnaires
gave a clear description of patient age, demographics and
possible status required for analysis. There was the ease of
relation between patient disease, diagnosis, and treatment. The
only difficult part in article two results was the fact that most
patients’ information was not recorded and actualized in the
system (Valiee et al.,2016)
Conclusions

The results from both studies show better analysis of patient
and caregiver relationships. Both cancer and vascular patients
improved on their chemotherapies and physiotherapies
respectively. However, the changing of positions in patients
with angiography complications was not satisfactory. The
quality of caregiving and relationship to patients proved
beneficial in determining caregiver professionalism and
possible distress. Future R & D should be done on cancer and
angiography treatments so that changes in patients are
ascertained despite the time taken.
References
Reblin, M., Donaldson, G., Ellington, L., Mooney, K., Caserta,
M., & Lund, D. (2016). Spouse cancer caregivers’ burden and
distress at entry to home hospice: The role of relationship
quality. Journal of Social and Personal Relationships, 33(5),
666–686. https://doi.org/10.1177/0265407515588220
http://ezproxy.snhu.edu/login?url=http://doi.org/10.1177/02654
07515588220
Valiee, S., Fathi, M., Hadizade, N., Roshani, D., & Mahmoodi,
P. (2016). Evaluation of feasibility and safety of changing body

position after transfemoral angiography: A randomized clinical
trial. Journal of Vascular Nursing, 34(3), 106–
115.http://dx.doi.org/10.1016/j.jvn.2016.05.001http://ezproxy.s
nhu.edu/login?url=http://search.ebscohost.com/login.aspx?direc
t=true&db=edselp&AN=S106203031630067X&site=eds-
live&scope=site
Article Review
Maria Williams
Article Review
Article Topic: Evaluation of feasibility and safety of changing
body position after transfemoral
angiography: A randomized clinical trial
Health Question: What are the effects of position change on the
acute complications of
coronary angiography?
Table 1: Article Findings
Variables
(Valiee et al., 2016)
P-Value

(Chair et al., 2007)
P- Value
Age
0.401
0.8
Height
0.151
1.0
Weight
0.52
0.9
Number of cigarettes smoked per day
0.076
1.0
Number of previous angiography
0.076
1.0
Systolic blood pressure
0.653
0.9
Implications
The two studies demonstrate that changing the positions of
patients after angiography based on the provided program
established creates no change in the incidences of vascular
complications, such as bleeding, thrombosis, as well as brui ses.
Additionally, the studies indicate no demographic connection
with the likelihood of getting the complications. In both the
first and second studies, the results indicate that none of the
participants experienced bleeding complications or hematoma.
Similar studies also suggest that there is no significant variation
between control groups and the intervention groups in the
incidence of hematoma and bleeding complications at the access
site following angiography. In light of the presented protocol,
the two studies suggest that it is safe and feasible to change the

patients’ position and allow early ambulation after coronary
angiography. More precisely, the two studies point to the
importance of body change in preventing health problems such
as backache, and physical discomfort.
Cardiovascular diseases are some of the leading causes of
deaths among women of all ethnic and racial groups. In
particular, heart disease remains one of the most problematic
complications, followed by coronary heart artery diseases.
Many diagnostic models are often employed to assess coronary
artery illnesses. One such tool is coronary angiography, which
provides the golden standard test for the disease. Angiography
is a process that entails injecting a radiopaque dye into the
coronary arteries under fluoroscopy, which determines the
condition of the coronary arteries and the degree of
atherosclerosis. Although the risks related to the utilization of
angiography are dependent upon the patient’s condition,
operators’ skills, and judgment, coupled with any invasive
process, may develop complications. As such, coronary
angiography may be accessed using the possible arteries, such
as brachial, radial, and femoral ones.
From the findings, therefore, changes in body position after
angiography does not result in change in the incidences of
cardiovascular complications for patients across all
demographic groups. On top of that, changing the body position
minimizes the risks of back pain, groin pain, and finally
improves the comfort of the patient. The aforementioned studies
reflect previous investigations carried out by different
researchers across varying patient groups. In that regard, other
studies are in agreement with the results because they indicate a
significant variation in the incidences of complications after
coronary angiography at the catheter insertion site between the
intervention and control groups. Other studies have also
attempted to examine the simultaneous impacts of early
ambulation and changes in body position using different
protocols from the study. Their time points for assessing the
patient in terms of complication were different. However, their

findings showed that changes in body position in and early
ambulation after the procedure did not increase cardiovascular
complications.
Bio statistical Calculations
The bio statistical tools that have been used to determine
the relationship between the variables is correlational analysis.
In particular, the p- value has been employed across the two
studies to assess the relationship between changing body
position and likelihood of having complications associated with
cardiovascular diseases such as heart disease and hematoma.
During null hypothesis significance testing, the p-value is
instrumental in determining the probability of obtaining test
outcomes at least as extreme as the results actually observed
when all factors and controls have been held constant. Thus, it
measures the possibility that the observed difference could have
occurred merely by random chance.
References
Chair, S., Thompson, D., & Li, S. (2007). The effect of
ambulation after cardiac catheterization
on patient outcomes. Journal of Clinical Nursing, 16(1), 212–
214.
Valiee, S., Fathi, M., Hadizade, N., Roshani, D., & Mahmoodi,
P. (2016). Evaluation of
feasibility and safety of changing body position after
transfemoral angiography: A
randomized clinical trial. Journal of Vascular Nursing, 34(3),
106–115.
Running Head: JOURNAL ARTICLE SELECTION

ARTICLE SELECTION
Journal: Article Selection
Maria Williams
Biostatistics
05/23/2021
Article Assignment
Module 2
Article 1
Article 2
Full APA Citation
Doering, L. V., McKinley, S., Riegel, B., Moser, D. K.,
Meischke, H., Pelter, M. M., & Dracup, K. (2010). Gender-
specific characteristics of individuals with depressive symptoms
and coronary heart disease. Heart & Lung: The Journal of
Critical Care, 40(3), e4–e14.
https://doi.org/10.1016/j.hrtlng.2010.04.002
http://ezproxy.snhu.edu/login?url=http://search.ebscohost.com/l
ogin.aspx?direct=true&db=cmedm&AN=20561880&site=eds-
live&scope=site
Frazier, L., Yu, E., Sanner, J., Liu, F., Udtha, M., Cron, S., & .
. . Bogaev, R. C. (2012). Gender differences in self-reported
symptoms of depression among patients with acute coronary
syndrome. Nursing Research & Practice, 1–5.
https://doi.org/10.1155/2012/109251

http://ezproxy.snhu.edu/login?url=http://search.ebscohost.com/l
ogin.aspx?direct=true&db=a9h&AN=86826621&site=eds-
live&scope=site
Purpose of study
To investigate the differences between men and women with
depressive symptoms and coronary heart disease.
To examine the prevalence of self-reported depressive
symptoms and the self-reported somatic depressive symptoms as
measured by the Beck Depression Inventory-II (BDI-II) among
patients hospitalized for acute coronary syndrome (ACS), and
explored the impact of gender on both
Research questions (or RQs—specifically what will be tested or
compared)
What are the differences between men and women with
depressive symptoms and coronary heart disease?
Are there differences in prevalence of self-reported depressive
symptoms and the self-reported somatic depressive symptoms
for men and women?
Module 5
Article 1
Article 2
Statistical Methods (see table below for description of each
possible test)
Cross-sectional design and multivariate regression modelling
Cho-square statistical test
What are the differences between men and women with
depressive symptoms and coronary heart disease?
Women were more likely to be single (OR 3.61, p < .001),
unemployed (OR 2.52, p < .001), poorly educated (OR 2.52, p <
.001), anxious (OR 1.14, p < .01), and to perceive lower control
over health (OR 1.34, p < .01) than males.

Are there differences in prevalence of self-reported depressive
symptoms and the self-reported somatic depressive symptoms
for men and women?
depressive symptoms during ACS episodes were different
between women and men. Women reported greater overall
depressive symptoms (BDI-II mean = 11.89, S.D. = 9.68) than
men (BDI-II mean = 9.00, S.D. = 7.93) (P < 0.000).
Significantly more women (7.66%) were identified positive for
somatic depressive symptoms (sleep and appetite disturbances
and fatigue) than men (2.22%) (P = 0.0003).
Additional Findings
Other findings show that Women with CHD and depressive
symptoms have fewer resources, greater anxiety, and lower
perceived control than men.
Gender variations occur in the depressive symptoms between
men and women
Module 6
Article 1
Article 2
Which specific statistical tests were used
P-test
Chi-Square tests
Similar methods between articles
Quantitative methods
Quantitative methods
Method differences
Cross-sectional design
Correlational methods
Strengths

The study can be generalized to different groups
The sample used was highly convenient
Limitations
Samples limited to the Caucasian population
Does not take into account the methodological caveats that must
be considered during data interpretation

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