BACKGROUND: Printed educational materials are widely used dissemination strategies to improve the quality of healthcare professionals' practice and patient health outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines. This is the fourth update of the review.
OBJECTIVES: To assess the effect of printed educational materials (PEMs) on the practice of healthcare professionals and patient health outcomes. To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on healthcare professionals' practice and patient health outcomes.
SEARCH METHODS: We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and EPOC Register from their inception to 6 February 2019. We checked the reference lists of all included studies and relevant systematic reviews.
SELECTION CRITERIA: We included randomised trials (RTs), controlled before-after studies (CBAs) and interrupted time series studies (ITSs) that evaluated the impact of PEMs on healthcare professionals' practice or patient health outcomes. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. Any objective measure of professional practice (e.g. prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included.
DATA COLLECTION AND ANALYSIS: Two reviewers undertook data extraction independently. Disagreements were resolved by discussion. For analyses, we grouped the included studies according to study design, type of outcome and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where data were available, we re-analysed the ITS studies by converting all data to a monthly basis and estimating the effect size from the change in the slope of the regression line between before and after implementation of the PEM. We reported median changes in slope for each outcome, for each study, and then across studies. We standardised all changes in slopes by their standard error, allowing comparisons and combination of different outcomes. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format. We assessed the risks of bias of all the included studies.
MAIN RESULTS: We included 84 studies: 32 RTs, two CBAs and 50 ITS studies. Of the 32 RTs, 19 were cluster RTs that used various units of randomisation, such as practices, health centres, towns, or areas. The majority of the included studies (82/84) compared the effectiveness of PEMs to no intervention. Based on the RTs that provided moderate-certainty evidence, we found that PEMs distributed to healthcare professionals probably improve their practice, as measured with dichotomous variables, compared to no intervention (median absolute risk difference (ARD): 0.04; interquartile range (IQR): 0.01 to 0.09; 3,963 healthcare professionals randomised within 3073 units). We could not confirm this finding using the evidence gathered from continuous variables (standardised mean difference (SMD): 0.11; IQR: -0.16 to 0.52; 1631 healthcare professionals randomised within 1373 units ), from the ITS studies (standardised median change in slope = 0.69; 35 studies), or from the CBA study because the certainty of this evidence was very low. We also found, based on RTs that provided moderate-certainty evidence, that PEMs distributed to healthcare professionals probably make little or no difference to patient health as measured using dichotomous variables, compared to no intervention (ARD: 0.02; IQR: -0.005 to 0.09; 935,015 patients randomised within 959 units). The evidence gathered from continuous variables (SMD: 0.05; IQR: -0.12 to 0.09; 6,737 patients randomised within 594 units) or from ITS study results (standardised median change in slope = 1.12; 8 studies) do not strengthen these findings because the certainty of this evidence was very low. Two studies (a randomised trial and a CBA) compared a paper-based version to a computerised version of the same PEM. From the RT that provided evidence of low certainty, we found that PEM in computerised versions may make little or no difference to professionals' practice compared to PEM in printed versions (ARD: -0.02; IQR: -0.03 to 0.00; 139 healthcare professionals randomised individually). This finding was not strengthened by the CBA study that provided very low certainty evidence (SMD: 0.44; 32 healthcare professionals). The data gathered did not allow us to conclude which PEM characteristics influenced their effectiveness. The methodological quality of the included studies was variable. Half of the included RTs were at risk of selection bias. Most of the ITS studies were conducted retrospectively, without prespecifying the expected effect of the intervention, or acknowledging the presence of a secular trend.
AUTHORS' CONCLUSIONS: The results of this review suggest that, when used alone and compared to no intervention, PEMs may slightly improve healthcare professionals' practice outcomes and patient health outcomes. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.
Healthcare professional are one stakeholder audience that public health nurses communicate with about relevant and current health information to inform their health promotion interventions. The study results are relevant to inform their knowledge translation strategies with this stakeholder audience.
This is an interesting question that addresses a common assumption we makes as practitioners. It is clear more research is needed in this area and consideration of factors such as social media etc.
This is a well written manuscript on the review of printed material. We, in health professions, use so much of printed material for ourselves and our patients; yet, do not have evidence that it is effective. This manuscript will help close that gap and provide areas for further research.
It's interesting to note that for printed educational material, there is no difference between printed or computerised versions of the same educational material to health care professionals practice.
This is an interesting article. I'm not sure that others would agree with the outcome.
Although the authors found 84 studies that met the inclusion criteria, 32 of which were RTs, they concluded that the quality of evidence prevented them from drawing any strong conclusions. The review suggested the printed educational material slightly improved health care professional's practice but could not draw conclusions about the effects of such materials on patient health.
I'm currently teaching nurses about behavioural change for cardiac patients. This is a good article for them to read to highlight the limitations of print materials only in encouraging patients to make health changes. I have added this as a course reading. Very timely.
I am not certain this study adds a lot due to the fact that as the authors noted, initial studies are retrospective in most cases.
This study, which set out to determine if printed material for health care professionals and patients were useful in the practice of health care and in patient outcomes, provided a conclusion that was slightly in favor of the information and cautiously uncertain. The entire study is quite lengthy. I would encourage us to utilize this helpful information when caring for patients now and in the future.
While continuing education and practice improvement remain goals for all clinicians, I think many suspect that written materials in isolation lead to small--even negligible--improvements in patient outcomes. While this is a very heterogeneous set of interventions and a meta-analysis may not be the best tool to address, this study confirms my prior belief that more innovative CME tools are necessary to affect significant change.
Healthcare professional routinely provide instructions to their patients particularly at the time of discharge. This review suggested that printed educational material may improve healthcare professionals' practice. This can enhance understanding of patients and their families and potentially can improve outcome.