1. 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

2. 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.

3. 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

4. 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

5. 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

6. 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)

7. 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

8. 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

9. 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

10. 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

11. Results: Readability Grade Level SMOG FRY AVE <7 6 1 8 3 4 9 10 26 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

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

13. 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.

14. 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

15. 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

16. Results SAM Score Not Suitable Adequate Superior Number of Materials15 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

17. 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%

18. 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

19. 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

20. 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/CCU The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of CDC or ASPH.