Introduction
Otitis media is a common childhood problem and is responsible for the majority of paediatric otolaryngology consultations. Up to 90 per cent of children are expected to have suffered the condition by the time they enter primary school.Reference Rosenfeld, Culpepper, Doyle, Grundfast, Hoberman and Kenna1
A great number of books, scientific articles and presentations, plus exhaustive internet resources, are available for clinicians and parents, providing information on the pathophysiology, presentation, complications and treatment of the condition. Much of this information refers to exceptional cases, is obsolete or is not of great interest to parents.
Therefore, the development of an information leaflet on otitis media with effusion (OME) could be useful in everyday clinical practice. The modified Delphi technique could be used as a means of gaining consensus on the content of such a leaflet. The leaflet was especially intended to provide information about OME to parents of children with the condition. The leaflet's purpose was to inform parents, in a simple, clear and quick manner, and to answer the majority of their questions, thus helping the clinician to perform a more thorough and efficient consultation.
Materials and methods
Medline and Google internet searches were performed using key words and terms, including otitis media, Delphi technique, and information leaflet or booklet. No study was identified which evaluated the content of an information leaflet for parents of children with OME, by using the Delphi technique. In order to reduce the number of rounds required in the Delphi method, a list of 23 OME-related facts was generated by the first two authors of the study (IMV and JH), with contributions from two parents. The list was then distributed to 18 doctors (three experienced paediatric otolaryngologists, two general head and neck surgeons, two otolaryngology residents, three paediatric residents, five paediatricians and three general practitioners) and to 17 parents of 10 children with OME who had visited one ENT out-patient clinic. The 23 items were related to the diagnosis, treatment, pathophysiology and prevention of OME. The 23 items were chosen on the basis of probably being of greatest interest to the parents, and being simple enough to be understood by the majority of non-medical subjects. Doctors and parents were asked to comment on the content of the leaflet, the clarity of the items and their necessity. Necessity was examined by one multiple choice question containing three possible answers: (a) very important, (b) important (i.e. good to know), and (c) less important (i.e. good to know but can omitted from the leaflet). Answer (a) was rated with 100 points, (b) with 50 points and (c) with no points. The mean score for each item was calculated by dividing the total points by the number of participants (doctors and parents). Items scoring less than 60 points in both groups were excluded from the second, revised list, which was distributed to 33 parents of 20 children.
Both lists were provided to parents, either immediately after OME was diagnosed, as part of the consultation process, or at the end of the consultation (as a summary).
Results and analysis
A total of 58 subjects participated in the study (18 doctors and 40 parents). Of these, two parents (of foreign origin) were excluded from the study due to their inability to read and understand the items.
The parents' and doctors' qualitative assessment of the first list of items differed, although both made positive and negative comments. Most of the doctors questioned the need for such a list, since they already explained the majority of the items to parents during the consultation. Moreover, the doctors feared that the abstract style of information presentation might confuse some parents, trigger more questions and prolong the consultation. On the other hand, the majority of the parents felt that such a leaflet (received from the doctor) would be useful, mostly because such written information would increase their trust in the doctor's statements and may reduce the need for additional information (and thus allay anxiety). Both parents and doctors commented, positively, that the information was presented in a relatively simple and clear fashion, and that it could increase compliance by increasing the reliability of doctors' input.
The results of the Delphi rounds, regarding the leaflet content, are presented in Table I. Items 3 and 14 were considered much more important by parents than by doctors (by a difference of more than 40 points), whereas items 7 and 19 were scored more highly by doctors. Items 4, 6, 8, 10, 20, 21 and 22, which mostly related to aetiology and surgical treatment, scored less than 60 in both groups and were thus excluded from the second list. (Since item 6, explaining the eustachian tube, was omitted, item 7 was modified in the second round to include this explanation.)
Table I Delphi technique results
Note that items 4, 6, 8, 10, 20, 21 and 22 were excluded from the second round.
The results of the second round are also shown in Table I. This revised list was distributed to 12 parents who had already participated in the first round and to 21 new parents who visited the ENT out-patient clinic. In this round, nine items scored greater than 70 (see Table I).
Discussion
In the current era of managed health services, research which aims to improve patients' satisfaction and compliance with treatment and to reduce unnecessary use of health resources is very useful. Informative leaflets on the prevention, diagnosis and treatment of various diseases and conditions, produced by health care trusts and other official organisations, have been shown to increase patients' satisfaction, knowledge and compliance.Reference Bellew, Atkinson, Dixon and Yates2–Reference O'Neill, Humphris and Field6 However, the actual effectiveness and cost-effectiveness of such leaflets have been questioned.Reference Lieu, Glauber, Fuentes-Afflick and Lo7, Reference Wilson, Brown and Stephens-Ferris8 Their usefulness has been recognised within preventive medicine (e.g. providing clear, reliable information on pneumococcal vaccines in order to increase vaccination rates).Reference Jacobson, Thomas, Morton, Offutt, Shevlin and Ray4 However, their effectiveness is much less certain within the context of clinical consultations for specific diseases (e.g. otitis media with effusion (OME)).
Qualitative assessment of the OME information leaflet showed that it had the potential to increase doctors' reliability and parents' satisfaction. This can be of great importance in private practice, where an increase in patients' satisfaction is more important than a reduction in consultation time. The impact of such leaflets on the management of chronic conditions remains to be quantified. However, developing their content, using the modified Delphi technique, can lead to some useful conclusions. Our findings show that the information doctors provide about a disease is not always the information patients (or their parents, in paediatric cases) want. The modified Delphi technique can improve doctors' understanding of patients' information needs. This can be especially useful for junior doctors, who have limited experience of interacting with patients.
The modified Delphi technique has already been used in the field of medical education, in the development of a psoriasis curriculum for medical students, and it has been shown to be useful in identifying important points within a chronic disease curriculum from the patient perspective.Reference Alahlafi and Burge9 Since ‘there is scope for more use of patient representation on boards and much greater input from patients in teaching and assessment’ and ‘patients will need to be more involved in education as well as in development of services’,Reference Hutchinson10 the application of the modified Delphi technique in the present study can be seen as a useful example of addressing such trends.
However, many methodological issues can arise from such applications of the technique, which remain to be clarified. These issues include: the number of Delphi rounds involved; whether the leaflet is provided during or after the consultation; and the numbers of doctors and patients (or parents) who should be involved. In this study, the second round was applied more to emphasise parents' opinions than to reduce the number of leaflet items. All of the items in the second list were included in the final information leaflet, but higher-scoring items were printed in bold characters. Thus, in this case, the second Delphi round can be regarded as a way of making the leaflet more ‘consumer friendly’, by indicating which items parents thought were more important.
KubbaReference Kubba11 has previously studied the impact on information leaflets of: the grade of existing evidence; the use of specific formulas (such as the Simple Measure of Gobbledegook formula) to test readability; and the use of pre-existing development guidelines. (However, in that particular study, the aim of the leaflet was to ‘help parents make an informed decision regarding surgery’ (i.e. tympanostomy tubes insertion).) The readability of the leaflet is of great concern, since ‘poor reading skills are surprisingly common in the general population and [amongst] otolaryngology patients in particular’.Reference Kubba12 The Delphi technique can prove useful on this point, by helping to choose the most ‘patient friendly’ sentences.
• Patients need to be more involved in medical education as well as in the development of health services
• Information leaflets can be an effective way to increase patients' knowledge about disease
• The Delphi technique is a useful method for identifying important points within a chronic disease curriculum, from the patient's perspective
• The information doctors provide on a disease is not always what the patients (or their parents in paediatric cases) want to know
• Use of the Delphi technique in the production of an information leaflet on otitis media with effusion can help reduce this discrepancy and increase the parents' satisfaction
Conclusion
Use of the modified Delphi technique showed that doctors and patients differed in their evaluation of the importance of medical information. Such differences could potentially result in less satisfactory consultations and reduced compliance. Several methodological issues require further discussion and research. Nevertheless, in this study, use of the modified Delphi technique in the production of an information leaflet on otitis media with effusion can be regarded as an attempt to increase patient input in medical education and in health services development.
