Scale Developing a pictorial Epworth Sleepiness

Objective The Epworth Sleepiness Scale (ESS) was designed to be self-completed by the patient. However, it may not be understood by all, and unrecognised problems with literacy can impair the process. The ESS has been translated into a pictorial version for use in those with normal or diminished literacy skills. Methods An evaluation of the patients’ ability to selfcomplete the ESS was undertaken in sleep and nonsleep respiratory clinics. Errors or problems encountered were recorded on a standard questionnaire. With the aid of a medical artist, pictorial representations of the eight ESS questions were developed and the new pictorial ESS was offered to patients alongside the traditional ESS. The two scales were compared for agreement with a kappa statistic, and patients were asked to record a preference for either the written or the pictorial scale. Results Evaluation of the traditional ESS showed that 33.8% (27/80) of ESS-naive patients made errors and 22.5% (18/80) needed help completing the questionnaire. The translated pictorial ESS showed good agreement with the traditional ESS on most questions; median kappa score 0.63, IQR 0.04. Fifty-five per cent reported a preference for the pictorial scale compared with the standard written ESS. Despite the fact that errors were frequently made on the traditional ESS, 96.8% of participants in the second study reported both scales to be easy to complete. More people (75.6%) reported the pictorial ESS to be very easy, in comparison with (64.6%) the worded ESS questionnaire. Conclusion Errors are common when patients selfcomplete the traditional written ESS. Pictures with words have been shown to enhance the understanding and translation of medical information, and a pictorial translation of the ESS produces scores comparable with the traditional ESS and may be a suitable alternative for those with normal or diminished literacy. INTRODUCTION Obstructive sleep apnoea syndrome (OSAS) is estimated to affect 5% of the adult population. 2 A key component of the disorder is excessive sleepiness in the daytime (EDS). Developed in 1991, the Epworth Sleepiness Scale (ESS) has become one of the most commonly used questionnaires to measure EDS. Designed to be self-administered, it asks the user to rate their level of sleepiness in eight different situations. Despite translation into several languages (including Chinese, German, Greek and Spanish), understanding of the scale is dependent on being able to read, write and interpret medical information. Our anecdotal experience suggests that patients have difficulty understanding and accurately self-completing the ESS. Difficulty with completing forms can occur for many reasons. The written word and numerals are not universally understood; problems with functional literacy in medicine are both common and underestimated. Pictures or pictorial aids are a useful adjunct to medical information and aid the transfer and comprehension of written and spoken information. Recall of medication and understanding of instructions have been shown to be improved when pictures are used in conjunction with, or instead of, the written word, even in those with normal literacy skills. Such interventions are important as they can improve both understanding and compliance with medical treatments. 15 16 This report describes an evaluation of patients’ ability to self-complete the ESS and a study of the translation of the standard ESS into a pictorial scale to produce a questionnaire that is suitable for all, irrespective of literacy.