EFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES

Effective Utilization of HealthCare Resources: An Educational Intervention for Adult Patients
Toyin Marcus
Arizona State University

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Abstract
Over the last ten years, a dramatic increase in Emergency Department (ED) visits has been
prominent. Non-emergent chief complaints, such as repeat chronic care needs, are causing
increased ED visits. The underutilization of primary care resources has been correlated with the
overutilization of emergency care resources. ED overutilization is having a negative rippling
effect on the ability of the US healthcare system to care for patients. Emergency department
personnel and other resources are strained, leading to overcrowding and decreased quality of
care. Health insurance and provider accessibility has been linked to the high rates of ED usage
by adults age 18 – 64, with the highest rates seen in those under public health coverage, such as
Medicaid, compared to those who were uninsured. To encourage primary care visits and
discourage non-emergent ED usage, the United States health system includes patient education
on the appropriate ED use, higher-copayment as financial disincentives, and encouragement of
provider-patient relationships with Primary care providers (PCP). The public health clinics,
including Federally Qualified Health Centers, provide patient education on the appropriate use of
PCP versus ED resources, and offer extended office hours during evenings and weekends;
trimming the rate of non-emergent ED visits can significantly reduce health care costs.
Keywords: ED utilization, Fotonovela, patient education

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Effective Utilization of HealthCare Resources: An Educational Intervention for Adult
Patients
The ineffective use of the Emergency Department (ED) is escalating health care costs per
individual, the cost of health insurance, while decreasing reimbursement rate, and the quality of
healthcare services provided (Bruni, Mammi, & Ugolini, 2016). The cost of obtaining quality
healthcare in the United States is at an all-time high, because some citizens neglect a proactive
concern for their health condition, choosing to visit the ED when their schedules permit, or when
their conditions escalate (Ondler, Hegde & Carlson, 2014). The public health insurance program
known as Medicaid, offers access to healthcare with little or no financial responsibility to the
patient. The National Health Statistics Report recently indicated that the highest frequencies of
emergency visits were found in the population with Medicaid coverage; this population also has
the highest rate of chronic medical disorders (Gindi, Black, & Cohen, 2016).
As a federal law, the Emergency Medical Treatment and Labor Act (EMTALA) compels
emergency departments to screen and provide necessary stabilizing care to anyone who requests
an exam, mandating emergency services to provide healthcare service to everyone who seeks
treatment. This inadvertently escalates healthcare cost through open access to emergency
medical care for low acuity illnesses and chronic disease (Dollinger, 2014). This has led to the
increased delay in diagnosing critical medical problems in the ED, thus raising healthcare costs.
As a result, overutilization of the ED and underutilization of primary health services are broadly
regarded as contributing factors to the inadequacies of the healthcare system (Bruni, Mammi, &
Ugolini, 2016). Due to inappropriate emergency service utilization, individuals in dire need of
emergency care can suffer needlessly. The healthcare services provided in the primary care

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setting can help reduce overutilization of ED, improve patient outcomes through more consistent
care and reduce overall healthcare costs. Consequently, developing and implementing an
effective educational program can drive primary care organizations to function at capacity, thus
reducing non-emergent, unwarranted ED visits and associated costs.
Purpose and Rationale
PCPs play a pivotal role when it comes to increasing access to low acuity care based
upon clinical research for effective solutions and policy implementation. It is important to
explore the growing concern regarding unproductive utilization of healthcare resources and its
ripple effect on society. The ineffective utilization includes allocating emergency/critical care
resources for chronic care, low acuity care, and non-urgent healthcare needs that PCPs are
qualified to address. This paper will discuss the background and significance of the growing
concerns regarding the ineffective utilization of healthcare resources, the ripple effect on society,
the healthcare system, review the current literature, and discuss the positive effects of
implementing the fotonovela program. This is a proven educational tool to improve patient
compliance, depicted in the synthesis table of the studies.
Background and Significance
Adult Emergency Department Patients
Over the last seven years, Americans spent approximately $2.4 trillion on healthcare
services, of which ED charges accounted for nearly $240 billion of the total cost (Ondler, Hegde
& Carlson, 2014). Inappropriate ED visits ranged between 20% and 80% of all non-emergent
services (Bruni, Mammi, & Ugolini, 2016). As the ineffective utilization of healthcare resources
continues to rise, the demand will continue to strain the national healthcare system (Shaw et al.,
2013). From 2013 to 2014, 7.9 million adults acquired public health insurance coverage (Gindi,

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Black, and Cohen, 2016). Gindi et al., further reported that the National Health Statistics
indicated that adults ages 18 through 64 with Medicaid coverage had the highest rate of ED
visits. The authors noted that the analyses performed by the National Survey on Medicaid
population indicated deprived health status and associated it with increased medical needs and
non-urgent ED visits among the age group. Uscher-Pines et al. (2013) described non-urgent ED
visit as seeking medical care for an illness in which a delay of service for several hours would
not result in an adverse outcome.
The unnecessary ED visits cause a wasteful allocation of national health resources,
increase nationwide healthcare cost, and create a disruption in the continuity of healthcare, which
leads to poor health outcomes (Bruni, Mammi, & Ugolini, 2016). The continuity of healthcare is
the relationship between the primary care provider and the patient. This relationship facilitates
vital health information and involves the plan of care development essential in the care of
complex chronical illness. This ensures progression towards the intended outcome (Pourat,
Davis, Chen, Vrungos, & Kominski, 2015). These researchers found that the people’s decisions
to choose the ED over PCP reflect the self-assessment of their healthcare needs, the accessibility,
and the financial requirement, insured versus uninsured.
Fotonovela Pamphlet
As the healthcare system becomes increasingly complex, people are overrun with the
compounded information that they can process, resulting in misinformation, adversely affecting
health and well-being. The World Health Organization (WHO), suggests that people with sound
health literacy are well-equipped to successfully use healthcare resources and enjoy healthy
outcomes (WHO, 2013). Due to the difficulty reading and digesting written information such as
handouts and package inserts, individuals with low health literacy increases non-compliance.

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Koops van’t Jagt and colleagues’ systematic review (2018) examined the effectiveness of healthrelated documents. It showed that visual narrative educational strategies are effective method of
delivering health information. Therefore, healthcare systems should not merely rely on words as
a communication tools. A Fotonovela is a pamphlet that incorporates pictures and captions to
reveal theatrical stories to capture the audience’s interest with its semi-realistic characters in
graphic pictures, coupled with simple phrases. Koops van’t Jagt et al (2018) concluded
Fotonovelas were narrative educational tools that assists people to facilitate information
processing, increases motivation to attain the main idea, and contributes to the transformation in
behaviors.
In California, a bilingual Fotonovela education on diabetes was used to assess 311
Hispanic adults with low literacy levels and showed a statistically significant knowledge gain
after reading the pamphlet (Koops van’t Jagt et al., 2018). The authors indicated the difficulties
in reading and understanding health information based only on a written form was less beneficial
than that of a booklet containing written information and graphic images.
Rate of Non-Emergency Department Visits
From January 1, 2013 to December 31, 2013 a sum of 163,951-people visited the ED, of
which 1.3% were uninsured and 38,579 did not require hospital admission or require ED services
(Erenler et. al, 2014). From the sum, 1,210-people revisited the ED within 24 hours and another
16,095-people revisited within a month. Therefore, a research project is essential to develop an
effective intervention to generate significant healthcare cost savings (Honigman, Wiler, Rooks,
& Ginde, 2013). Stakeholders such as the health systems, providers, and payers formulated
various national healthcare initiatives to depress the non-emergent ED visits. This includes
patient education and financial disincentives. The healthcare initiatives also consist of

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interventions to increase the availability of PCP which was expected to meet the demands of
people who might report themselves to the ED. This gave rise to the extension of PCP office
hours into the evening, weekends, and Saturday clinic hours at the peak time. Xin, Kilgore, Sen,
& Blackburn (2015) reported that some diseases addressed within the PCP office hours had a
price tag of $600 - $900 more expensive per each ED encounter. The authors also indicated an
estimated $6 to $9 million in cost savings for a 5% reduction of non-urgent ED visits and a $29
to $43 million for a 25% reduction. Similarly, Uscher-Pines et al. (2013) projected an annual
savings of $4.4 billion if the primary care visits were addressed in the providers' offices or in
retail clinics.
Internal Evidence
A local faith-based community health clinic in southern Arizona has been unable to
combat the problem of overutilization of the ED and underutilization of primary health services.
The clinical director reported that besides verbal education, there is no formal teaching tool used
to reduce ED overuse. Approximately 24% of patients’ report seeking non-urgent medical care in
the ED (B. Berrera, personal communication, March 27, 2019). Patient educational methods
need to change to effect in knowledge and attitudes necessary to maintain or improve health
(AAFP, 2019). For integrated clinics to maintain their federal and state funding, alternative
educational programs proven to increase patient compliance must be explored with the goal of
reducing ineffective health resource utilization in adult patients aged 18 to 64 years old. This
inquiry led to the clinically relevant PICOT question, “In a primary care clinic, how does the use
of a Fotonovela booklet as an educational tool for 18 to 64-year-old adult patients affect the nonurgent ED visits over a six-weeks’ timeframe?”.

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Problem Statement
In 2014, 18% of adults accounted for 20% of the total ED visits for non-emergent care
(Gindi, Black, & Cohen, 2016). Such ineffective utilization of emergency resources continues to
grow exponentially, creating tensions on ED resources, escalating health care costs and
compromising healthcare of critically ill people.
Search Strategies
An exhaustive search was conducted using the following databases: Cumulative Index to
Nursing and Allied Health (CINAHL), PubMed Central (National Library of Medicine), PubMed
(National Institutes of Health), ScienceDirect, and MEDLINE (ProQuest) to assist in the primary
search of literature relevant to the clinical problem. To yield pertinent studies that address each
component of the research question, key terminologies used included:
P (Patient or Population)
I (intervention/indicator)
C (comparison)
O (outcome of interest)
T (Time)

Adult patients ages 18 to 64 years’ old
Fotonovela booklet
verbal education
impact on non-emergent ED visits
Six-weeks’ timeframe

Also, key terminologies used included: “emergency room costs for non-emergencies, non-urgent
emergency room cost, cost of non-emergent ER visit, non-urgent emergency room cases, nonurgent emergency visits, emergency room (and) primary care use, hospital emergency services,
emergency room (and) non-emergent use, emergency room for non-emergencies, “effective
utilization of primary care (OR) emergency room usage,” “non- emergency treatment in
emergency department,” “non-urgent emergency visit (OR) non-emergent ER visit, “primary
care (and) emergency department (and) non-urgent emergency visit.” Inclusion criteria were
articles written in the English language, including publications within the last 5 years.

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The CINAHL database had the option to further filter results to case studies and age
group limits while this filter yielded seven articles (Appendix A). PubMed searches found 62
initial items, which was further narrowed using Medical Subject Headings (MeSH) terms,
leaving 21 articles of relevance (Appendix B). ScienceDirect initially found 97 articles, of which
only one was applicable. This finding provided links to other recommended articles based upon
the selected topic. However, similar articles were already selected from PubMed. For MEDLINE
ProQuest, my first search result was zero, however after refining the search, it yielded 405 items.
I then limited it to a five-year timeframe and ended with 25 articles (Appendix C). From all the
databases searched, 10 articles were selected: two Systematic Reviews, one Randomized
Controlled Trial, one quasi-experimental, two Retrospective Study, two Case Control Study, one
Cross Sectional Study, and one Case Report were incorporated into this clinical inquiry.
Critical Appraisal and Evidence Synthesis
Rapid Critical Appraisal (RCA) was conducted for the literature reviews selected. The
articles were selected based upon the level of evidence. After reviewing the ten studies, all the
study designs met the scientific standards. The level of evidence ranges from systemic reviews,
randomized trials being as higher levels of evidence and the observational studies as a lower
level of evidence. All aspects of the study’s design conducted and analyzed were transparent to
the benefits and harms. According to the literature, a benefit of not using the ED for nonemergency concerns is developing continuity of care with a PCP who can facilitate care for
chronic and subacute conditions. The harms of this practice include the inappropriate ED
admission for non-emergency services.
The studies followed a valid research process and the instruments used for intervention
resulted in improved access to primary care, which helped to reduce unnecessary ED utilization

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and improved patient health outcomes. In the articles, the authors adhered to the concept that
consistency in the methods of responding to the questionnaires/surveys, and the outcomes remain
fairly the same using the t-test method. Some of the studies clearly defined the risk and outcome
in the objective section while others covered the material in the validated methods section. To
avoid biased results, the participants were selected from the same general population and
underwent rigorous inclusion criteria, which are similar across the studies. Only three studies
explicitly indicated their exclusion. The articles also include measures such as an ongoing
discussion between the authors to verify the coding scheme, interpretation, and conclusion.
The datasets are homogeneous because they incorporate people/ individuals with similar
demographics. To illustrate this, the sample populations were chosen because they have similar
traits in age and location. For example, the data set is made up of adults 18 to 64 years old and
the traits selection and location were meaningful to the study conducted. Also, there was no
indication of male to female ratio. One of the systematic reviews studied the literature on
interventions in various categories encompass the rest of the 9 articles and the overall outcomes
were analogous in the proportion of the high user of ED resources.
Conceptual Framework
Koops van’t Jagt and colleagues (2018) conducted a focus study to explore the effects of
Fotonovela on patients diagnosed with depression. Researchers report a statistically significant
knowledge gain in the fotonovela group. To guide this potential project, a theoretical model of
the patient’s decision-making process to visit the ED for a non-emergency medical condition,
coupled with an (Appendix F) Entertainment Overcoming Resistance Model (EORM), an
effective health communication tool such as a leaflet that can illustrate a theatrical story using
photographs and captions can captivate the audience. The outcome is substantial to future studies

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alike. Similarly, a four weeks’ study using a literacy and culturally fit narrative communication
as a tool for health behavior changes would be conducted parallel to the study stated above while
raising cognitive process whereby readers can imagine himself or herself as a certain character.
Evidence-Based Practice Model
The ACE Star model of change (Appendix G) has been chosen to guide the proposed
educational intervention (Schaffer, Sandau & Diedrick, 2013). The model offers a
comprehensive outline that systematizes Evidence Based Practice (EBP) processes using five
points of knowledge transformation; thus, transform knowledge generated from research into a
report that provides relevant and valuable information to the patients in a literacy and culturally
appropriate fotonovela pamphlet. This can be integrated into practice, and then evaluated for the
impact of EBP and the effect of ED usage. Evaluating how appropriate variables were used in
the studies can underline the contributions made the research studies. Incorporating the method
to distinguish the proposed project’s variables and to propose resolutions to the barriers may lead
to a success in minimizing the ineffective utilization of healthcare resources.
Project Method
The Institutional Review Board at Arizona State University approved this project
(Appendix H). Prior to project implementation, the clinical site also approved the project to be
conducted at their clinic (Appendix I), after determining that the project was going to be
beneficial. Ms. Beatriz Barrera, patient care coordinator, accessed the Care Empower database
and extracted patients’ ED visit histories with a high number of ED visits. Dr. Mark Schildt,
Medical Director, granted access to the patient’s chart record. The inclusion criteria included
adult clients ages 18 to 64 who are able to consent, either English and/or Spanish speaking, with
a minimum history of one non-emergent ED visit within the last six months. Exclusion criteria

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include special populations and anything outside of the inclusion. Chart audits were conducted
retrospectively and cross-referenced with the inclusion criteria (Appendix J). Participants were
identified from the list generated from the Empower system, an Electronic Health Information
(EHI) exchange database. A retrospective chart audit was conducted for those who met inclusion
criteria and they were presented with recruitment letters and consent forms. Kang et al. (2013)
reported the validity and reliability of patient selections based on medical record review for testretest as 0.641 and 0.974. A demographic questionnaire as a baseline pre-test (Appendix I), and a
15 min Fotonovela educational session were conducted (Appendix J). Six weeks later, a post-test
survey (Appendix I) was conducted on five participants who completed the survey, EHI and a
chart audit were used to assess changes in ED use. Also, a pre and post-survey interview were to
collect demographic and intervention assessment questionnaire answers from the subjects.
The outcome variable for this project is the rate of ED utilization. An indication of a
successful outcome would be an effective utilization of healthcare resources, a 50% reduction in
the rate of non-emergent ED visits in six weeks. Also, an ultimate decrease in healthcare costs.
Using EORM’s persuasive narrative methodologies to guide the interrelated concepts of using
simple text to create a visual narrative story with photographs and captions to illustrate realistic
characters to engage participants, can inspire participants to accept the key message and induce a
behavior change. The ACE star model incorporates the established nursing process and the
distinctive aspect of EBP Through the five points, the ACE star model is able to provide a
methodical assimilation of Fotonovela evidence into clinical practice. The Fotonovela content
can be acquired through the first three stages of ACE star model; knowledge discovery, evidence
summary. In the last two stages, implementation can enable Fotonovela integration, which can

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lead to improved quality of care and the evaluation of the strategy and outcome can provide vital
information which can be improved before incorporating it into the current practice.
Outcomes/Project Results/Impact
The study sample consisted of seven adult patients, with only 5 completing the follow-up
survey (N=5) in a primary care clinic. It was identified that 4 (80%) had taxpayer-funded health
insurance and 1 (20%) was uninsured. All the participants’ income range from $0 to 25,999, all
below the federal poverty level. The majority of sample with high school education 3 (60%) and
the remainder with some college credit 2 (40%).

Table 1

Valid 2.0
4.0
6.0
8.0
Total

preHealth Visits to ED
Frequency
1
2
1
1
5

Percent
20.0
40.0
20.0
20.0
100.0

Valid Percent
20.0
40.0
20.0
20.0
100.0
Table 1

Cumulative
Percent
20.0
60.0
80.0
100.0

In this table, the scores in the first column are the number of visits by the participants.
Participants had taken between 2 and 8 visits prior to the intervention. The Frequency column
shows how many participants visited the ED. One participant had 2 visits, two participants had 4
visits each, one participant had 6 visits and one participant had 8 visits. The frequencies were
converted to percentages in the percent column. We can conclude the participants had an average
of 4 ED visits (40%) or more. All participants visited the ED and the PCP. One visited the retail
clinic and one visited the free clinic.
Table 2

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Valid

.00

PostHealth Visits to ED6a
Valid
Frequency Percent
Percent
5
100.0
100.0

14

Cumulative
Percent
100.0

Table 2
In this table, the scores in the first column are the number of visits by the participants.
Therefore, no participant visited ED after the intervention. The frequency column shows number
of participants; all five participants did not make any visit. We can conclude that all of the
participants (100 %) did not visits the ED after intervention.
Before the intervention, participants indicated: 2 (40%) preferred walk-in, 2 (40%)
indicated regular doctor is closed, and 1 (20%) indicated the problem could only be addressed in
the ED. The complaints were evenly distributed across major systems (100%). The complaints
were evenly distributed across major systems (100%). Within the six-week post-health visits
intervention period, all the participants visited the PCP, no participants visited the ED and Free
Clinic.
The majority of the participants were Caucasian 3 (60%) and the remainder were
Hispanic 2 (40%). The sample consisted of 2 (40%) females and 3 (60%) male participants. The
average age of the participants is 52 (SD=13.71) and the ages ranged from 22 to 61 years of age.
The average rate of ED visits before intervention is 4.57 (SD= 2.94) and the ED visits ranged
from 2 to 11. The average rate of ED visits after intervention is zero. All participants agreed that
access to a primary care physician would be beneficial. According to the post-rating booklet, the
participants had no reasons to visit the ED and reported that 1) the booklet kept their interest and
attention; 2) information in the booklet was trustworthy; and 3) the teaching methods helped
distribute meaningful knowledge on the effective use of the ED and PCP. The five participants

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learn about effective utilization of PCP vs ED with the Fotonovela method. A pre and post-test
of the measurement of the effectiveness of the tool was taken on a scale, where 1= Not at all
effective to 5= very effective method. The result indicated that after measurement, it showed a
decreased overuse of ED resources (average rank of 3 to 0).
The Fotonovela education reduced the rate of ED visits by an effect size of 1.5, a
significant improvement between pre- and post-intervention. All participants agreed that access
to primary care physicians, after-hour services, a one-on-one nurse care, and access to mental
health services would be beneficial, however access to online appointment scheduling would not
be beneficial. Two participants believed after-hour services are vital, four agreed that one-on-one
nurse care would beneficial while three think transportation to appointment could be helpful,
four believe access to mental health services would be helpful, all participants does not believe
that online appointment scheduling is beneficial, and four out of five participants think referral to
specialist would be helpful in achieving their desired health level.
Reporting Outcome Variables
The SPSS 25.0 software bundle was used to analyze the data obtained. At the end of the study,
the researcher grouped and evaluated the participants’ complaints and reasons for the ED visits.
The research conducted paired-test to evaluate average score of the pre- and post- Health
Information National Trends Survey (HINTS), which was developed by National Cancer
Institute (NCI) to fill the gap in health communication and health promotion on a populationwide basis (Nelson, 2004).

EFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES
Table 3
Descriptive Statistics
N
preRateED
postRateED
PreHINTS
postHINTS
totalScore
Valid N (listwise)

5
5
5
5

Minimu Maximu
m
m
3.00
4.00
.00
.00
14.00
29.00
7.00
16.00

Mean
3.8000
.0000
21.8000
13.2000

16

Std.
Deviation
.44721
.00000
6.90652
3.83406

5
Table 3

Among the participants that that took the Fotonovela education, (N=5), there was a
statistically significant difference between the pre- and post ED visits, pre- ED visits (M=3.80,
SD = .45) and post ED visits (M=0, SD = .00), p<.05.
Further, Cohen’s effect size value (d=1.5) suggested a high practical significance. The
results were worthwhile because they are relevant to the clinical practice because the effect size
(ES): Cohen’s d (ED visits) = 21.80 – 13.20 = 1.539
5.58
Z = 1.539 indicates there is large difference between the mean of pre-test and post-test. The
difference between the two test is more than 1 standard deviation.

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Table 4
Ranks
N
postRateED – preRateED

d

Negative Ranks

Positive Ranks
Ties
Total
a) postRateED < preRateED
b) postRateED > preRateED
c) postRateED = preRateED

5

0e
0f
5

Mean Rank Sum of Ranks
3.00
15.00
.00

.00

Table 4

Table 5
Test Statisticsa

postRateED preRateED
-2.121b
.034

Z
Asymp. Sig. (2tailed)
a. Wilcoxon Signed Ranks Test
b. Based on positive ranks.
Table 5

The Wilcoxon test will be run due to low number of participants and will be used to
examine whether there was a difference in the ED rate before and after a 6 week Fotonovela
educational program (i.e., dependent variable is the “ED rate”, and the two related groups are the
values of ED rate before and after the intervention program). The output from table 4 and 5 is
from the Wilcoxon test conducted in SPSS. The difference between the two means is an
indication that Fotonovela intervention which had a large effect on increasing knowledge. The
SPSS test output contained a z-value of -2.12 and a p-value of 0.034,’? which is less than 0.05.
Hence, we can confirm that there is significant difference between the 2 tests.

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.
Five participants learn about effective utilization of PCP vs ED with the Fotonovela
method. A pre and post-test of the measurement of the effectiveness of the tool was taken on a
scale, where 1= Not at all effective to 5= very effective method. The result indicated that after
measurement, it showed a decreased overuse of ED resources (average rank of 3 to 0).
Table 6
null: null

Table 6
The Wilcoxon signed ranked test showed that the observed difference between both the pre- and
post-ED visits is significant; therefore, we can reject the null hypothesis, which states that there
will be no difference after the Fotonovela intervention. We can assume that the teaching method
is effective, thus resulted in a significant decrease in the rate of ED visits.
The null hypothesis states that there will be no difference in the participants ED visits rate post
intervention. The alternate hypothesis states that the intervention has an effect on the participants
and the no. of visits will be lesser than the current visits.
Discussion
The purpose this project was to study the effect of Fotonovela to educate adult patients
with high ED visits to gain decision-making knowledge to seek health care appropriately over 6

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weeks at SEHC and reduce overutilization of ED resources. The researcher found that the mean
ED visits over six weeks post-Fotonovela intervention in primary care setting declined
significantly among ED overuse. These results indicated that, over a short period, Fotonovela
may be an effective intervention tool in playing a small role in preventing primary care related
ED use. This finding may be associated with cost savings because program implementation costs
are lesser than ED visits costs. This project, however, did not include the cost of participants’ ED
visits. A longitudinal study of ED visits and costs pre/post intervention may be warranted for
further investigation.
Conclusion
Fotonovela entertaining educational tool can positively affect primary care related ED overuse.
The evidence indicated that through the narrative structure of EORM, educational messages can
overcome reactance by diminishing the viewer’s perception that the messages is intended to
persuade. A commonality in barriers noted for this project includes low health literacy and low
socioeconomic factors. A change in ED visit rate was observed after the project, which directly
correlated to a decrease in non-urgent ED visits. This means reduced missed appointments (noshow and late cancellation), which can help stimulate the practice site’s revenue. This can also
enable the patients to establish a more effective provider-patient relationship with their PCP and
improves patients’ ability to participate in shared-decision making about their health. Reduction
in ED use can divert patients to PCP thereby significantly decreasing health care expenditures,
thus health care costs.
Fotonovela tools are feasible and economically worthwhile. The fiscal costs include
copyright, printing costs, and staff associated costs. The total amount of cost is yet to be

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determined. Clinical factors included incorporating Fotonovela education into the current routine
and effectively managing resistance to routine change.

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adults aged 18-64: National Health Interview Survey, 2013 and 2014. National Health
Statistics Reports, (90), 1-16.
HolaDoctor. (2015). Fotonovela: “An Ounce of Prevention”. Retrieved from
https://www.countyofglenn.net/resources/health-parenting-family-prevention-youth/hpvfotonovela-ounce-prevention.
Honigman, L. S., Wiler, J. L., Rooks, S., & Ginde, A. A. (2013). National study of non-urgent
emergency department visits and associated resource utilization. Western Journal of
Emergency Medicine, 14(6), 609. Doi:10.5811/westjem.2013.5.16112

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Kang, B. S., Cheong, H. K., Jung, K. Y., Jang, S. H., Yoo, J. K., Kim, D. W., ... & Lee, S. Y.
(2013). The validity and reliability of characterizing epilepsy based on an external review
of medical records. Epidemiology and health, 35.
Koops van’t Jagt, R., Hoeks, J. C., Duizer, E., Baron, M., Molina, G. B., Unger, J. B., & Jansen,
C. J. (2018). Sweet Temptations: How does reading a fotonovela about diabetes affect
dutch adults with different levels of literacy? Health Communication, 33(3), 284-290.
https://doi.org/10.1080/10410236.2016.1258617
Littlejohn, S.W., Foss, K.A., & Oetzel, J.G. (2017). Theories of Human Communication (11th
ed.) Long Grove, IL: Waveland Press
Morgan, S. R., Chang, A. M., Alqatari, M., & Pines, J. M. (2013). Non–emergency department
interventions to reduce ED utilization: a systematic review. Academic Emergency
Medicine, 20(10), 969-985.
Nelson, D. E., Kreps, G. L., Hesse, B. W., Croyle, R. T., W, G., Willis, Arora, N. K., . . . Alden,
S. (2004). The Health Information National Trends Survey (HINTS): Development,
design, and dissemination. Journal of Health Communication, 9(1),443-460. Retrieved
from https://pdfs.semanticscholar.org/1617/c97ed2584fd54988bc845cd0308209d74c76
.pdf
Ondler, C., Hegde, G. G., & Carlson, J. N. (2014). Resource utilization and health care charges
associated with the most frequent ED users. The American journal of emergency
medicine, 32(10), 1215-1219.
Pourat, N., Davis, A. C., Chen, X., Vrungos, S., & Kominski, G. F. (2015). In California,
primary care continuity was associated with reduced emergency department use and

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fewer hospitalizations. Health Affairs (Project Hope), 34(7), 1113–1120.
http://doi.org/10.1377/hlthaff.2014.1165
Schaffer, M. A., Sandau, K. E., & Diedrick, L. (2013). Evidence-based practice models for
organizational change: Overview and practical applications. Journal of Advanced
Nursing, 69(5), 1197–1209. doi:10.1111/j.1365-2648.2012.06122.x
Shaw, E. K., Howard, J., Clark, E. C., Etz, R. S., Arya, R., & Tallia, A. F. (2013). Decisionmaking processes of patients who use the emergency department for primary care needs.
Journal of Health Care for the Poor and Underserved, 24(3), 1288-1305.
Stangroom, J. (2019). Effect Size Calculator for T-Test. Retrieved from
https://www.socscistatistics.com/effectsize/default3.aspx
Uscher-Pines, L., Pines, J., Kellermann, A., Gillen, E., & Mehrotra, A. (2013). Deciding to visit
the emergency department for non-urgent conditions: a systematic review of the
literature. The American journal of Managed Care, 19(1), 47.
Weisz, D., Gusmano, M. K., Wong, G., & Trombley, J. (2015). Emergency department use: a
reflection of poor primary care access? The American journal of managed care, 21(2),
e152-60.
World Health Organization (WHO). (2013). Health literacy: The solid facts. Health. Retrieved
from: http://www.euro.who.int/__data/assets/pdf_file/0008/190655/e96854.pdf
Xin, H., Kilgore, M. L., Sen, B. P., & Blackburn, J. (2015). Can nonurgent emergency
department care costs be reduced? Empirical evidence from a US nationally
representative sample. Journal of Emergency Medicine, 49(3), 347-354.

EFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES
Appendix A
Figure 2 Cumulative Index to Nursing and Allied Health Plus

24

EFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES
Appendix B
Figure 1 PubMed

25

EFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES
Appendix C
Figure 3 MEDLINE (ProQuest)

26

EFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES
Appendix D

Table 1
Evaluation Table
Citation
Gingold, D. B.,
(2017). Impact
of the
affordable care
act Medicaid
expansion on
emergency
department
high utilizers
with
ambulatory
care sensitive
conditions
Country: US
Funding: No
outside funding
Bias: None

9

Conceptual
Framework
HSM

Design/
Method/
Sampling
Design: CSS
Method:
Differencesindifferences
approach
using logistic
regression to
investigate
differences
between high
and low
utilizer
cohorts
changed
from before
and after
expansion

Sample/Settin
g
Sample:
Yr. 1: n
=17,795
Yr. 2: n
=16,456
Setting:
ED at PGHC, a
public safetynet hospital in
Cheverly,
Maryland, a
suburb of
Washington
D.C.

Variables
DV– ED
utilizers:
high & Low
IV – # of ED
visit

Measurement/
Instrumentati
on
Picis ED
PulseCheck

Data
Analysis
SAS
Universit
y Edition
Studio
version
3.4

Findings/
Themes

After
Medicaid
expansion,
there was an
overall
increase
in ED
two tailed utilization
Student's
t-test

Level
Evidence
Level IV

Pearson
χ2 test
logistic
regressio
n

Note: ACSCs-Ambulatory Care–Sensitive Conditions, AZ-Arizona, BHIP-Brooklyn Health Care Improvement Project, CA-California, CHCF-California
Healthcare Foundation, CV- Control Variable, CMED-Conceptual Model of Emergency Department, GT-Grounded theory, DV-Dependent variable, DMDiabetes Mellitus, DMP- Decision Making Process, EMR-Electronic Medical Records, ED- Emergency Department, EORM-Entertainment Overcoming
Resistance Model, EC-Exclusion Criteria, GMDH-General Medical Surgical Hospital, HBM-Health Belief Model, HL-High Literacy, HUM-Healthcare
Utilization Model, HSM-Health System Model, BHM-Behavioral Model of Health Services, IC-Inclusion Criteria, IV- Independent Variable, LG- Literacy
Group, LL-Low Literacy, LRM-Linear Regression Models, MEPS-Medical Expenditure Panel Survey MIB- Model of Illness Behavior, NE-Nonemergent, NVNevada, n- Sample Population, OBS- observational, %-Percent, Pts- Patients, PCP- Primary Care Provider, PHC-Persuasive Health Communication, PGHCPrince George's Hospital Center, RCT- Randomized Control Trial, RCS-Retrospective Cross-Sectional Study, SPO-Structure Process Outcomes, SSI-SemiStructured Interviews, SM-System model, SPARCS-Statewide Planning and Research Cooperative System, SR-Systematic review, TC-Trauma Center, USUnited States, Yr. 1-2013, Yr. 2-2014

EFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES

10

Table 1
Evaluation Table
Citation

Gindi, R. M.
(2016).
Reasons for
emergency
room use
among US
adults aged 1864
Country: US
Funding:
Not disclosed
Bias: None

Conceptual
Framework

HBM

Design/
Method/
Sampling

Design:
Case Report
Method:
Multipurpose
health survey
conducted
continuously.
Data are
collected in
person

Sample/Settin
g

Sample:
Adult aged:
18-64 years
Yr. 1: n =
26,825
Yr. 2: n =
28,053

Variables
IV: % adult
who visited
ED, Reasons
for most
recent visit

Measurement/
Data
Instrumentati
Analysis
on

SUDAAN
software
version 11.0.0,
a
DV:
software
Seriousness
package
of medical
designed to
problem,
account for
doctor’s
the complex
office or
sampling
clinic was
design of
not open, and
National
lack of
Health
access
Interview
provider
Survey
(NHIS).

Findings/
Themes

Level
Evidence

Few
Regressio changes in
n models ER use were
noted
between
Level II
2013 and
2014.

Note: ACSCs-Ambulatory Care–Sensitive Conditions, AZ-Arizona, BHIP-Brooklyn Health Care Improvement Project, CA-California, CHCF-California
Healthcare Foundation, CV- Control Variable, CMED-Conceptual Model of Emergency Department, GT-Grounded theory, DV-Dependent variable, DMDiabetes Mellitus, DMP- Decision Making Process, EMR-Electronic Medical Records, ED- Emergency Department, EORM-Entertainment Overcoming
Resistance Model, EC-Exclusion Criteria, GMDH-General Medical Surgical Hospital, HBM-Health Belief Model, HL-High Literacy, HUM-Healthcare
Utilization Model, HSM-Health System Model, BHM-Behavioral Model of Health Services, IC-Inclusion Criteria, IV- Independent Variable, LG- Literacy
Group, LL-Low Literacy, LRM-Linear Regression Models, MEPS-Medical Expenditure Panel Survey MIB- Model of Illness Behavior, NE-Nonemergent, NVNevada, n- Sample Population, OBS- observational, %-Percent, Pts- Patients, PCP- Primary Care Provider, PHC-Persuasive Health Communication, PGHCPrince George's Hospital Center, RCT- Randomized Control Trial, RCS-Retrospective Cross-Sectional Study, SPO-Structure Process Outcomes, SSI-SemiStructured Interviews, SM-System model, SPARCS-Statewide Planning and Research Cooperative System, SR-Systematic review, TC-Trauma Center, USUnited States, Yr. 1-2013, Yr. 2-2014

EFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES

11

Table 1
Evaluation Table
Citation
Koops van’t
Jagt, R. (2018).
Sweet
Temptations:
How does
reading a
fotonovela
about diabetes
affect dutch
adults with
different levels
of literacy
Country: US
Funding: No
outside funding
Bias: None

Conceptual
Framework
EORM

Design/
Method/
Sampling
Design:
RCT
Method:
Participants
from both
groups were
randomly
assigned to
one of three
conditions:
fotonovela
condition,
traditional
brochure
condition,
and a control
condition.
All
participants
filled out

Sample/Settin
g
Sample: 202
(age 16 - 65)
LL-group (N =
89)
HL-group (N =
113)
Setting
Participants in
low LG were
recruited from
literacy
courses/literac
y meetings
HL–
participants
group were
recruited from
family

Measurement/
Data
Instrumentati
Analysis
on
DV-1:
Univariat
Literacy (low Fotonovela
e analysis
and high)
booklet
of
variance
Traditional
brochure
IV-1:
DM
knowledge,
behavioral
intentions
Variables

IV-EORM:
variables
measuring
entertainmen
t featurestransportatio
n,
identification
, and
perceived

Findings/
Themes

Level
Evidence

The
Level I
outcomes of
this study
suggest that
a fotonovela
may be a
valuable
health
education
format for
adults
with varying
levels of
literacy.

Note: ACSCs-Ambulatory Care–Sensitive Conditions, AZ-Arizona, BHIP-Brooklyn Health Care Improvement Project, CA-California, CHCF-California
Healthcare Foundation, CV- Control Variable, CMED-Conceptual Model of Emergency Department, GT-Grounded theory, DV-Dependent variable, DMDiabetes Mellitus, DMP- Decision Making Process, EMR-Electronic Medical Records, ED- Emergency Department, EORM-Entertainment Overcoming
Resistance Model, EC-Exclusion Criteria, GMDH-General Medical Surgical Hospital, HBM-Health Belief Model, HL-High Literacy, HUM-Healthcare
Utilization Model, HSM-Health System Model, BHM-Behavioral Model of Health Services, IC-Inclusion Criteria, IV- Independent Variable, LG- Literacy
Group, LL-Low Literacy, LRM-Linear Regression Models, MEPS-Medical Expenditure Panel Survey MIB- Model of Illness Behavior, NE-Nonemergent, NVNevada, n- Sample Population, OBS- observational, %-Percent, Pts- Patients, PCP- Primary Care Provider, PHC-Persuasive Health Communication, PGHCPrince George's Hospital Center, RCT- Randomized Control Trial, RCS-Retrospective Cross-Sectional Study, SPO-Structure Process Outcomes, SSI-SemiStructured Interviews, SM-System model, SPARCS-Statewide Planning and Research Cooperative System, SR-Systematic review, TC-Trauma Center, USUnited States, Yr. 1-2013, Yr. 2-2014

EFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES

12

Table 1
Evaluation Table
Citation

Conceptual
Framework

Morgan, S.
CMED(2013). Non–
crowding
emergency
department
interventions to
reduce ED
utilization
Country: US
Funding:
Not disclosed

Design/
Sample/Settin
Method/
g
Sampling
questionnaire members
/acquaintances
of PHC
students

Design: SR
Method:
Systematical
reviewed the
literature on
the
effectiveness
of non-ED
interventions

Sample:
39 studies, 34
OBS & 5 RCT
Setting:
literature
review on
interventions
IC: Patient
education on
medical
conditions and

Variables
similarity,
entertainmen
t features
variables:
counterargui
ng and
perceived
vulnerability
DV: Patient
education;
Additional
non-ED
capacity;
Managed
care;
Prehospital
diversion,
and Patient
financial
incentives.

Measurement/
Data
Instrumentati
Analysis
on

Grading of
Recommendati
ons
Assessment,
Development,
and Evaluation
(GRADE)
guideline.

Studies
were
observati
onal

Findings/
Themes

Intervention
s with the
greatest
number of
studies
showing
reductions
in ED use
include
patient
financial
incentives
and

Level
Evidence

Level I

Note: ACSCs-Ambulatory Care–Sensitive Conditions, AZ-Arizona, BHIP-Brooklyn Health Care Improvement Project, CA-California, CHCF-California
Healthcare Foundation, CV- Control Variable, CMED-Conceptual Model of Emergency Department, GT-Grounded theory, DV-Dependent variable, DMDiabetes Mellitus, DMP- Decision Making Process, EMR-Electronic Medical Records, ED- Emergency Department, EORM-Entertainment Overcoming
Resistance Model, EC-Exclusion Criteria, GMDH-General Medical Surgical Hospital, HBM-Health Belief Model, HL-High Literacy, HUM-Healthcare
Utilization Model, HSM-Health System Model, BHM-Behavioral Model of Health Services, IC-Inclusion Criteria, IV- Independent Variable, LG- Literacy
Group, LL-Low Literacy, LRM-Linear Regression Models, MEPS-Medical Expenditure Panel Survey MIB- Model of Illness Behavior, NE-Nonemergent, NVNevada, n- Sample Population, OBS- observational, %-Percent, Pts- Patients, PCP- Primary Care Provider, PHC-Persuasive Health Communication, PGHCPrince George's Hospital Center, RCT- Randomized Control Trial, RCS-Retrospective Cross-Sectional Study, SPO-Structure Process Outcomes, SSI-SemiStructured Interviews, SM-System model, SPARCS-Statewide Planning and Research Cooperative System, SR-Systematic review, TC-Trauma Center, USUnited States, Yr. 1-2013, Yr. 2-2014

EFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES

13

Table 1
Evaluation Table
Citation
Bias:
None

Conceptual
Framework

Design/
Method/
Sampling

Sample/Settin
g

Variables

appropriate
IV: ED visit
medical care
use for lowacuity
conditions;
Creation of
additional
capacity in
non-ED
settings; PCP
Managed care;
Prehospital
diversion, and
Patient
financial
incentives
EC: Telephone
triage and case
Management

Measurement/
Data
Instrumentati
Analysis
on

Findings/
Themes

Level
Evidence

managed
care, while
the greatest
magnitude
of
reductions
was found
in
pt education

Note: ACSCs-Ambulatory Care–Sensitive Conditions, AZ-Arizona, BHIP-Brooklyn Health Care Improvement Project, CA-California, CHCF-California
Healthcare Foundation, CV- Control Variable, CMED-Conceptual Model of Emergency Department, GT-Grounded theory, DV-Dependent variable, DMDiabetes Mellitus, DMP- Decision Making Process, EMR-Electronic Medical Records, ED- Emergency Department, EORM-Entertainment Overcoming
Resistance Model, EC-Exclusion Criteria, GMDH-General Medical Surgical Hospital, HBM-Health Belief Model, HL-High Literacy, HUM-Healthcare
Utilization Model, HSM-Health System Model, BHM-Behavioral Model of Health Services, IC-Inclusion Criteria, IV- Independent Variable, LG- Literacy
Group, LL-Low Literacy, LRM-Linear Regression Models, MEPS-Medical Expenditure Panel Survey MIB- Model of Illness Behavior, NE-Nonemergent, NVNevada, n- Sample Population, OBS- observational, %-Percent, Pts- Patients, PCP- Primary Care Provider, PHC-Persuasive Health Communication, PGHCPrince George's Hospital Center, RCT- Randomized Control Trial, RCS-Retrospective Cross-Sectional Study, SPO-Structure Process Outcomes, SSI-SemiStructured Interviews, SM-System model, SPARCS-Statewide Planning and Research Cooperative System, SR-Systematic review, TC-Trauma Center, USUnited States, Yr. 1-2013, Yr. 2-2014

EFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES

14

Table 1
Evaluation Table
Citation
Ondler, C.
(2014).
Resource
utilization and
health care
charges
associated with
the most
frequent ED
users
Country: US
Funding:
Not disclosed
Bias: None

Conceptual
Framework
HBM,
HUM

Design/
Method/
Sampling
Design:
Descriptive
statistics

Measurement/
Instrumentati
on
Sample: n=
IV: ED
Standardized
216
visits:
statistical
108 Frequent
frequent and collection tool
and
non-frequent with standard
Method: RS 108 nondefinitions of
(Retrospectiv frequent users
DV:
the
e Study)
Demographic predetermined
characteristic variables.
Setting:
, distance
ED at our
urban, teaching lived from
hospital,
hospital
medical and
psychiatric
hx, substance
abuse his,
diagnostic
testing,
disposition,
and cost for
visit.
Sample/Settin
g

Variables

Level
Evidence

Data
Analysis

Findings/
Themes

χ2 for
proportio
ns and t
test,
Wilcoxon
rank sum
based on
normality
of the
data

Frequent
Level IV
users have
unique
medical and
social
characteristi
cs; however,
disposition
and visit
charges did
not differ
from
nonfrequent
users.

Note: ACSCs-Ambulatory Care–Sensitive Conditions, AZ-Arizona, BHIP-Brooklyn Health Care Improvement Project, CA-California, CHCF-California
Healthcare Foundation, CV- Control Variable, CMED-Conceptual Model of Emergency Department, GT-Grounded theory, DV-Dependent variable, DMDiabetes Mellitus, DMP- Decision Making Process, EMR-Electronic Medical Records, ED- Emergency Department, EORM-Entertainment Overcoming
Resistance Model, EC-Exclusion Criteria, GMDH-General Medical Surgical Hospital, HBM-Health Belief Model, HL-High Literacy, HUM-Healthcare
Utilization Model, HSM-Health System Model, BHM-Behavioral Model of Health Services, IC-Inclusion Criteria, IV- Independent Variable, LG- Literacy
Group, LL-Low Literacy, LRM-Linear Regression Models, MEPS-Medical Expenditure Panel Survey MIB- Model of Illness Behavior, NE-Nonemergent, NVNevada, n- Sample Population, OBS- observational, %-Percent, Pts- Patients, PCP- Primary Care Provider, PHC-Persuasive Health Communication, PGHCPrince George's Hospital Center, RCT- Randomized Control Trial, RCS-Retrospective Cross-Sectional Study, SPO-Structure Process Outcomes, SSI-SemiStructured Interviews, SM-System model, SPARCS-Statewide Planning and Research Cooperative System, SR-Systematic review, TC-Trauma Center, USUnited States, Yr. 1-2013, Yr. 2-2014

EFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES

15

Table 1
Evaluation Table
Citation
Sabik, L.
(2017).
Changes in
emergency
department
utilization after
early Medicaid
expansion in
California
Country: US
Funding:
Robert Wood
Johnson
Foundation
Bias: None

Conceptual
Framework

Quasiexperimental
framework

Design/
Method/
Sampling

Design:
LRM
Method:
QE

Sample/Settin
g
Sample:
Adults ages
18–64
IC: short-term,
nonfederal,
MSH EDs in
CA, NV, AZ

Variables

IV: # of
visits by pt.
with
Medicaid,
commercial
insurance,
and
uninsured

EC: 13
hospitals
without full 16 DV:
quarters of data total and NE
over study
ED
period
CG: CA
expansion
counties

Measurement/
Data
Instrumentati
Analysis
on

Survey, ED
algorithm

linear
regressio
n

Findings/
Themes

Similar
trends
across both
sets of
counties
over time
and an
increase in
total ED
visits across
both groups

Level
Evidence

Level III

Note: ACSCs-Ambulatory Care–Sensitive Conditions, AZ-Arizona, BHIP-Brooklyn Health Care Improvement Project, CA-California, CHCF-California
Healthcare Foundation, CV- Control Variable, CMED-Conceptual Model of Emergency Department, GT-Grounded theory, DV-Dependent variable, DMDiabetes Mellitus, DMP- Decision Making Process, EMR-Electronic Medical Records, ED- Emergency Department, EORM-Entertainment Overcoming
Resistance Model, EC-Exclusion Criteria, GMDH-General Medical Surgical Hospital, HBM-Health Belief Model, HL-High Literacy, HUM-Healthcare
Utilization Model, HSM-Health System Model, BHM-Behavioral Model of Health Services, IC-Inclusion Criteria, IV- Independent Variable, LG- Literacy
Group, LL-Low Literacy, LRM-Linear Regression Models, MEPS-Medical Expenditure Panel Survey MIB- Model of Illness Behavior, NE-Nonemergent, NVNevada, n- Sample Population, OBS- observational, %-Percent, Pts- Patients, PCP- Primary Care Provider, PHC-Persuasive Health Communication, PGHCPrince George's Hospital Center, RCT- Randomized Control Trial, RCS-Retrospective Cross-Sectional Study, SPO-Structure Process Outcomes, SSI-SemiStructured Interviews, SM-System model, SPARCS-Statewide Planning and Research Cooperative System, SR-Systematic review, TC-Trauma Center, USUnited States, Yr. 1-2013, Yr. 2-2014

EFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES

16

Table 1
Evaluation Table
Citation

Conceptual
Framework

Design/
Method/
Sampling

Sample/Settin
g

Variables

IG:
NV and AZ
counties

Measurement/
Data
Instrumentati
Analysis
on

Findings/
Themes

Level
Evidence

Atlas.ti
(Atlas.ti
Scientific
Software
Development
GmbH, Berlin,
Germany), a
qualitative soft
ware
program that
facilitates

Findings
Level V
highlight
that future
endeavors to
improve
health care
service
delivery
cannot
overlook the
power of

Setting:
short-term,
nonfederal,
GMSH EDs in
CA, NV, AZ
Shaw, E. K.
(2013).
Decisionmaking
processes of
patients who
use the
emergency
department for
primary care
needs

BHM
Grounded
theory

GT
Design:
Qualitative
Study
Method:
CCS: (Case
Control
Study)
Audio-

Sample:
n=30 patients
who sought
treatment in
ED
Setting:
Urban Level I
adult ED TC
and a tertiary
care center for
multiple

IV: Patients’
DMP
DV:
ED nonurgent visit

Qualitati
ve
analytic
approach

Note: ACSCs-Ambulatory Care–Sensitive Conditions, AZ-Arizona, BHIP-Brooklyn Health Care Improvement Project, CA-California, CHCF-California
Healthcare Foundation, CV- Control Variable, CMED-Conceptual Model of Emergency Department, GT-Grounded theory, DV-Dependent variable, DMDiabetes Mellitus, DMP- Decision Making Process, EMR-Electronic Medical Records, ED- Emergency Department, EORM-Entertainment Overcoming
Resistance Model, EC-Exclusion Criteria, GMDH-General Medical Surgical Hospital, HBM-Health Belief Model, HL-High Literacy, HUM-Healthcare
Utilization Model, HSM-Health System Model, BHM-Behavioral Model of Health Services, IC-Inclusion Criteria, IV- Independent Variable, LG- Literacy
Group, LL-Low Literacy, LRM-Linear Regression Models, MEPS-Medical Expenditure Panel Survey MIB- Model of Illness Behavior, NE-Nonemergent, NVNevada, n- Sample Population, OBS- observational, %-Percent, Pts- Patients, PCP- Primary Care Provider, PHC-Persuasive Health Communication, PGHCPrince George's Hospital Center, RCT- Randomized Control Trial, RCS-Retrospective Cross-Sectional Study, SPO-Structure Process Outcomes, SSI-SemiStructured Interviews, SM-System model, SPARCS-Statewide Planning and Research Cooperative System, SR-Systematic review, TC-Trauma Center, USUnited States, Yr. 1-2013, Yr. 2-2014

EFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES

17

Table 1
Evaluation Table
Citation

Conceptual
Framework

Funding:
Not disclosed
Bias: None

Design/
Method/
Sampling
recorded
interviews
transcribed
into Atlas
Cycles of
immersion/cr
ystallization
to analyze
transcripts

Sample/Settin
g

Variables

specialties

Measurement/
Data
Instrumentati
Analysis
on
analysis.

IC: age 21 or
older, able to
speak English
or Spanish,
local resident,
triaged in ED’s
non-urgent
area
EC: no
exception

Uscher-Pines,
L. (2013).
Deciding to
visit the
emergency
department for
non-urgent

HUM
MIB

Design:
conducted a
systematic
review of the
peerreviewed and
grey

Sample:
63 articles
Setting:
IC: Full text
from 26
articles

DV: Visit
ED for nonurgent
condition
IV: younger
age, ED for

Standardized
data form to
collect
information
from
included
articles.

All the
studies
were
observati
onal in
nature
and the

Findings/
Themes

Level
Evidence

patient
perceptions
that shape
their
decisions to
use the ED
vs. other
health
care
facilities for
non- urgent
needs.
Age,
convenience
of the ED
compared to
alternatives,
referral to
the ED by a

Level V

Note: ACSCs-Ambulatory Care–Sensitive Conditions, AZ-Arizona, BHIP-Brooklyn Health Care Improvement Project, CA-California, CHCF-California
Healthcare Foundation, CV- Control Variable, CMED-Conceptual Model of Emergency Department, GT-Grounded theory, DV-Dependent variable, DMDiabetes Mellitus, DMP- Decision Making Process, EMR-Electronic Medical Records, ED- Emergency Department, EORM-Entertainment Overcoming
Resistance Model, EC-Exclusion Criteria, GMDH-General Medical Surgical Hospital, HBM-Health Belief Model, HL-High Literacy, HUM-Healthcare
Utilization Model, HSM-Health System Model, BHM-Behavioral Model of Health Services, IC-Inclusion Criteria, IV- Independent Variable, LG- Literacy
Group, LL-Low Literacy, LRM-Linear Regression Models, MEPS-Medical Expenditure Panel Survey MIB- Model of Illness Behavior, NE-Nonemergent, NVNevada, n- Sample Population, OBS- observational, %-Percent, Pts- Patients, PCP- Primary Care Provider, PHC-Persuasive Health Communication, PGHCPrince George's Hospital Center, RCT- Randomized Control Trial, RCS-Retrospective Cross-Sectional Study, SPO-Structure Process Outcomes, SSI-SemiStructured Interviews, SM-System model, SPARCS-Statewide Planning and Research Cooperative System, SR-Systematic review, TC-Trauma Center, USUnited States, Yr. 1-2013, Yr. 2-2014

EFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES

18

Table 1
Evaluation Table
Citation

Conceptual
Framework

conditions: A
systematic
review of the
literature
Funding:
CHCF

Funding:
New York

Sample/Settin
g
EC:
lack of
quantitative
data and nonU.S. patients

Variables
convenience,
referral to
ED, negative
perception
about PCP

Measurement/
Data
Instrumentati
Analysis
on
majority
did
not use
multivari
ate
statistics.

Method:
SR

Bias: None
Weisz, D.
(2015).
Emergency
department
use: A
reflection of
poor primary
care access?

Design/
Method/
Sampling
literature to
identify
factors
associated
with nonurgent ED

HCM

Design:
Survey
research
design
Method:
CCS (casecontrol
study)

Sample:
11,546 patients
Setting:
Survey data
from three
different:
ACSCs, New
York
SPARCS,
BHIP

IV: Age,
gender,
race/ethnicity Population, and primary based
payer.
administrative
data set
DV: ED
visits

Findings/
Themes

Level
Evidence

physician,
and negative
perceptions
about
alternatives
all play a
role in
driving
nonurgent
ED use.
Survey and
insurance
encounter
data suggest
Logistic
many
Level V
regressio Medicaid
n analysis pts
chose ED
because
healthcare
system

Note: ACSCs-Ambulatory Care–Sensitive Conditions, AZ-Arizona, BHIP-Brooklyn Health Care Improvement Project, CA-California, CHCF-California
Healthcare Foundation, CV- Control Variable, CMED-Conceptual Model of Emergency Department, GT-Grounded theory, DV-Dependent variable, DMDiabetes Mellitus, DMP- Decision Making Process, EMR-Electronic Medical Records, ED- Emergency Department, EORM-Entertainment Overcoming
Resistance Model, EC-Exclusion Criteria, GMDH-General Medical Surgical Hospital, HBM-Health Belief Model, HL-High Literacy, HUM-Healthcare
Utilization Model, HSM-Health System Model, BHM-Behavioral Model of Health Services, IC-Inclusion Criteria, IV- Independent Variable, LG- Literacy
Group, LL-Low Literacy, LRM-Linear Regression Models, MEPS-Medical Expenditure Panel Survey MIB- Model of Illness Behavior, NE-Nonemergent, NVNevada, n- Sample Population, OBS- observational, %-Percent, Pts- Patients, PCP- Primary Care Provider, PHC-Persuasive Health Communication, PGHCPrince George's Hospital Center, RCT- Randomized Control Trial, RCS-Retrospective Cross-Sectional Study, SPO-Structure Process Outcomes, SSI-SemiStructured Interviews, SM-System model, SPARCS-Statewide Planning and Research Cooperative System, SR-Systematic review, TC-Trauma Center, USUnited States, Yr. 1-2013, Yr. 2-2014

EFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES

19

Table 1
Evaluation Table
Citation

Conceptual
Framework

State Health
Care Efficiency
and
Affordability
Law grant

Design/
Method/
Sampling

Sample/Settin
g

Design:
MEPS

Sample: n=
1287

Variables

Measurement/
Data
Instrumentati
Analysis
on

Bias: Yes
(Grant is goal
specific)
Xin, H. (2015).
Can nonurgent
emergency
department
care costs be
reduced?
Empirical
evidence from
a US nationally
representative
sample

SPO

Method:
Retrospectiv
e cohort
designs

Ages (18-34),
(35-64),
(65 and older)
Setting:
In person ED

IV: SPO
Model
(Usual
source of
care,
perceived
convenience
needed
medical care,
and pts care
quality

Survey
procedures
in STATA
(version 12;
StataCorp LP,
College
Station, TX)
Prevention
quality

Multivari
ate
analysis

Findings/
Themes

Level
Evidence

failed to
provide
easily
accessible,
culturally
competent,
timely,
quality PCP.
Improveme
nt in
ambulatory
care quality
as potential
target area
to
effectively
reduce
nonurgent
ED care

Level IV

Note: ACSCs-Ambulatory Care–Sensitive Conditions, AZ-Arizona, BHIP-Brooklyn Health Care Improvement Project, CA-California, CHCF-California
Healthcare Foundation, CV- Control Variable, CMED-Conceptual Model of Emergency Department, GT-Grounded theory, DV-Dependent variable, DMDiabetes Mellitus, DMP- Decision Making Process, EMR-Electronic Medical Records, ED- Emergency Department, EORM-Entertainment Overcoming
Resistance Model, EC-Exclusion Criteria, GMDH-General Medical Surgical Hospital, HBM-Health Belief Model, HL-High Literacy, HUM-Healthcare
Utilization Model, HSM-Health System Model, BHM-Behavioral Model of Health Services, IC-Inclusion Criteria, IV- Independent Variable, LG- Literacy
Group, LL-Low Literacy, LRM-Linear Regression Models, MEPS-Medical Expenditure Panel Survey MIB- Model of Illness Behavior, NE-Nonemergent, NVNevada, n- Sample Population, OBS- observational, %-Percent, Pts- Patients, PCP- Primary Care Provider, PHC-Persuasive Health Communication, PGHCPrince George's Hospital Center, RCT- Randomized Control Trial, RCS-Retrospective Cross-Sectional Study, SPO-Structure Process Outcomes, SSI-SemiStructured Interviews, SM-System model, SPARCS-Statewide Planning and Research Cooperative System, SR-Systematic review, TC-Trauma Center, USUnited States, Yr. 1-2013, Yr. 2-2014

EFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES

20

Table 1
Evaluation Table
Citation
Funding:
Not disclosed
Bias:
None

Conceptual
Framework

Design/
Method/
Sampling

Sample/Settin
g

Variables
evaluation).
DV: Urgent
vs. nonurgent
ED care cost
CV: age,
gender,
race/ethnicity
, rural/urban
location,
insurance
status

Measurement/
Data
Instrumentati
Analysis
on
indicators
(PQIs).

Findings/
Themes

Level
Evidence

costs.

Note: ACSCs-Ambulatory Care–Sensitive Conditions, AZ-Arizona, BHIP-Brooklyn Health Care Improvement Project, CA-California, CHCF-California
Healthcare Foundation, CV- Control Variable, CMED-Conceptual Model of Emergency Department, GT-Grounded theory, DV-Dependent variable, DMDiabetes Mellitus, DMP- Decision Making Process, EMR-Electronic Medical Records, ED- Emergency Department, EORM-Entertainment Overcoming
Resistance Model, EC-Exclusion Criteria, GMDH-General Medical Surgical Hospital, HBM-Health Belief Model, HL-High Literacy, HUM-Healthcare
Utilization Model, HSM-Health System Model, BHM-Behavioral Model of Health Services, IC-Inclusion Criteria, IV- Independent Variable, LG- Literacy
Group, LL-Low Literacy, LRM-Linear Regression Models, MEPS-Medical Expenditure Panel Survey MIB- Model of Illness Behavior, NE-Nonemergent, NVNevada, n- Sample Population, OBS- observational, %-Percent, Pts- Patients, PCP- Primary Care Provider, PHC-Persuasive Health Communication, PGHCPrince George's Hospital Center, RCT- Randomized Control Trial, RCS-Retrospective Cross-Sectional Study, SPO-Structure Process Outcomes, SSI-SemiStructured Interviews, SM-System model, SPARCS-Statewide Planning and Research Cooperative System, SR-Systematic review, TC-Trauma Center, USUnited States, Yr. 1-2013, Yr. 2-2014

EFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES

21

Appendix E
Table 2
Synthesis Table
Author

Gingold

Gindi

Koops

Morgan

Ondler

Sabik

Shaw

Year
LOE
IV
ED Low
Users
ED High
Users
ED Nonurgent visit
ED Urgent
visit
LG
DV
Additional
non-ED
capacity
Age
Behavioral
intentions

2017

2016

2018

2013

2014

2017

IV

II

I

I

IV

X

X

X

X
X

X

X

X

Weisz

Xin

2013

UscherPines
2013

2015

2015

III

V

V

V

IV

X

X

X

X

X

X

X

X

ns

ns

ns

Note: ACSCs-Ambulatory Care–Sensitive Conditions, AZ-Arizona, BHIP-Brooklyn Health Care Improvement Project, CA-California, CHCF-California
Healthcare Foundation, CV- Control Variable, CMED-Conceptual Model of Emergency Department, GT-Grounded theory, DV-Dependent variable, DMDiabetes Mellitus, DMP- Decision Making Process, EMR-Electronic Medical Records, ED- Emergency Department, EORM-Entertainment Overcoming
Resistance Model, EC-Exclusion Criteria, GMDH-General Medical Surgical Hospital, HBM-Health Belief Model, HL-High Literacy, HUM-Healthcare
Utilization Model, HSM-Health System Model, BHM-Behavioral Model of Health Services, IC-Inclusion Criteria, IV- Independent Variable, LG- Literacy
Group, LL-Low Literacy, LOE-Level Of Evidence, LRM-Linear Regression Models, MIB- Model of Illness Behavior, NE-Nonemergent, NV-Nevada, n- Sample
Population, ns-Not significant, OBS- observational, %-Percent, PCP- Primary Care Provider, PHC-Persuasive Health Communication, PGHC-Prince George's
Hospital Center, RCT- Randomized Control Trial, RCS-Retrospective Cross-Sectional Study, SPO-Structure Process Outcomes, SS-Statistically Significant, SSISemi-Structured Interviews, SM-System model, SPARCS-Statewide Planning and Research Cooperative System, SR-Systematic review, TC-Trauma Center, USUnited States, Yr-Year, Yr. 1-2013, Yr. 2-2014, ↓ - Reduced, ↑ - Increased

EFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES

22

Table 2
Synthesis Table
Clinic closed
DM
knowledge
Convenience
Referral
ED Visits
Ethnicity
Financial
Incentive
Gender
Insurance
Level of care
Negative
Perception
No provider
Managed
care
Medicaid
Patient
education
Prehospital
diversion
Uninsured

ns



ns

ns
ns



SS






ns
SS
ns

ns












Note: ACSCs-Ambulatory Care–Sensitive Conditions, AZ-Arizona, BHIP-Brooklyn Health Care Improvement Project, CA-California, CHCF-California
Healthcare Foundation, CV- Control Variable, CMED-Conceptual Model of Emergency Department, GT-Grounded theory, DV-Dependent variable, DMDiabetes Mellitus, DMP- Decision Making Process, EMR-Electronic Medical Records, ED- Emergency Department, EORM-Entertainment Overcoming
Resistance Model, EC-Exclusion Criteria, GMDH-General Medical Surgical Hospital, HBM-Health Belief Model, HL-High Literacy, HUM-Healthcare
Utilization Model, HSM-Health System Model, BHM-Behavioral Model of Health Services, IC-Inclusion Criteria, IV- Independent Variable, LG- Literacy
Group, LL-Low Literacy, LOE-Level Of Evidence, LRM-Linear Regression Models, MIB- Model of Illness Behavior, NE-Nonemergent, NV-Nevada, n- Sample
Population, ns-Not significant, OBS- observational, %-Percent, PCP- Primary Care Provider, PHC-Persuasive Health Communication, PGHC-Prince George's
Hospital Center, RCT- Randomized Control Trial, RCS-Retrospective Cross-Sectional Study, SPO-Structure Process Outcomes, SS-Statistically Significant, SSISemi-Structured Interviews, SM-System model, SPARCS-Statewide Planning and Research Cooperative System, SR-Systematic review, TC-Trauma Center, USUnited States, Yr-Year, Yr. 1-2013, Yr. 2-2014, ↓ - Reduced, ↑ - Increased

Running head: INEFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES
Appendix F
Figure 4

(Littlejohn, Foss & Oetzel 2016)

23

INEFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES
Appendix G
Figure 5

(Schaffer, Sandau & Diedrick, 2013)

24

INEFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES
Appendix H
Figure 6

APPROVAL: MODIFICATION
CONHI: DNP
602/496-0730
Judith.Ochieng@asu.edu
Dear Judith Ochieng:
On 1/18/2019 the ASU IRB reviewed the following protocol:

Type of Review: Modification
Title: Effective Utilization of Healthcare Resources: A
Fotonovela Educational Intervention for Adult
Primary Care Patients.
Investigator: Judith Ochieng
IRB ID: STUDY00008799
Funding: None
Grant Title: None
Grant ID: None

25

INEFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES

26

Appendix I
Figure 7

St. Elizabeth's
HEALTH CENTER
December 5, 2018
To Arizona State University Institutional Review Board:
It is my pleasure to write this letter of support for DNP candidate Toyin Marcus and her Doctor
of Nursing Practice (DNP) graduate project proposal entitled "Effective Utilization of Healthcare
Resources: A Fotonovela Educational Intervention for Adult Primary Care Patients."
I have reviewed her project proposal, and am in support of her conducting her research at our
Health Center.
Respectfully,

Mark Schildt, MD
Chief Medical
Officer
marks@saintehc.or
g (520)628-7871

PHONE (520) 628-7871 • FAX (520) 205-8461 • 140 W Speedway Blvd, Suite 100 • Tucson, AZ 85705 • www.saintehc.org

INEFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES

27

Appendix J
Figure 8

ID #
+
Last 4 of
pt.
Phone#
100
101
102
103
104
105
106
107
108
109
110

AGE/
YEARS

GENDER
1 Male
2 Female

DX

Fotonovela Education
Patient Follow up
Chart Audit
Insured
0= No insurance
1= AHCCCS
2= Medicare
3= private

Active date ED (rate of ED visit)

Description
(reason for
ED visit)
HCAP
H/P

INEFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES

28

Appendix K
Figure 9

Study ID:
1.
a.
b.
c.

Survey Questionnaire
Pre-Intervention

How old are you?
18 to 25 years
26 to 49 years
50 to 64 years

2. What was your total household income last year?
a. $0 to 25,999
b. $26, 000 to 51,999
c. $52,000 to 74,999
d. $75,000 or more
3.
a.
b.
c.
d.
e.
f.

What is your race/ethnicity?
American Indian / Native American
White / Caucasian
Black / African American
Hispanic / Latino
Asian or Pacific Islander
Other________________________

4. Education: What is the highest degree or level of school you have completed? If
currently enrolled, mark the previous grade or highest degree received.
a.
No schooling completed
b.
Nursery school to 8th grade
c.
9th, 10th or 11th grade
d.
12th grade, no diploma
e.
High school graduate - high school diploma or the equivalent (for example: GED)
f.
Some college credit, but less than 1 year
g.
1 or more years of college, no degree
h.
Associate degree (for example: AA, AS)
i.
Bachelor's degree (for example: BA, AB, BS)
j.
Master's degree (for example: MA, MS, MEng, MEd, MSW, MBA)
k.
Professional degree (for example: MD, DDS, DVM, LLB, JD)
l.
Doctorate degree (for example: PhD, EdD)
5. Which was the primary reason you decide to use the emergency department?
a. My regular doctor is closed right now
b. My regular doctor told me to come to the emergency department
c. The emergency department costs me less money than my usual source of care to resolve my
health issue

INEFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES

29

d. The emergency department takes less time than my usual source of care to resolve my health
issue
e. The wait time in the ED is shorter than the wait time at my usual source of care
f. I prefer not to schedule an appointment (I prefer to walk-in and be seen without an
appointment)
g. The ED is more convenient than my usual source of care
h. My problem can only be addressed in a hospital/ emergency department (emergent issue)
i. I had nowhere else to go
j. Not Answered
6. During the past year, how many times have you visited the following places to receive
medical care?
Location
a. An Emergency Department
b. Doctor’s Office
c. Retail Clinic (such as CVS Minute Clinic or
Beuhler’s Quick Clinic)
d. Free Clinic (such as Open M)
e. Other (specify)

Frequency in past 12
months

7. Would the following help you achieve the level of health you want?

Not Answered

No

a. Access to a primary care physician
b. After-hours options for minor health issues besides the emergency department
c. A nurse to work with one-on-one to help manage health care needs
d. Transportation to get to medical appointments on-time
e. Access to mental or behavioral health services
f. Online appointment scheduling
g. Referral to a specialist (such as pain management)
h. Other (write in)
9. Do you currently have health insurance?

Yes

No

Not Answered

10. If yes, what kind of health insurance do you have?
a. Private insurer (insurance through your (or family member’s) employer, or private
insurance which you have purchased such as Anthem, Medical Mutual of Ohio
(MMO), Aetna, or COBRA)
b. Medicaid
c. Medicare, including Medicare advantage plans
d. Other ________________________________ (write-in)
e. Not Answered

Yes

NA

INEFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES
Appendix L
Figure 10

(HolaDoctor, 2015)

30

INEFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES

31

Appendix M
Figure 9

Study ID:
2.
d.
e.
f.

Survey Questionnaire
Post- Intervention

How old are you?
18 to 25 years
26 to 49 years
50 to 64 years

2. What was your total household income last year?
e. $0 to 25,999
f. $26, 000 to 51,999
g. $52,000 to 74,999
h. $75,000 or more
4.
g.
h.
i.
j.
k.
l.

What is your race/ethnicity?
American Indian / Native American
White / Caucasian
Black / African American
Hispanic / Latino
Asian or Pacific Islander
Other________________________

4. Education: What is the highest degree or level of school you have completed? If
currently enrolled, mark the previous grade or highest degree received.
m.
No schooling completed
n.
Nursery school to 8th grade
o.
9th, 10th or 11th grade
p.
12th grade, no diploma
q.
High school graduate - high school diploma or the equivalent (for example: GED)
r.
Some college credit, but less than 1 year
s.
1 or more years of college, no degree
t.
Associate degree (for example: AA, AS)
u.
Bachelor's degree (for example: BA, AB, BS)
v.
Master's degree (for example: MA, MS, MEng, MEd, MSW, MBA)
w.
Professional degree (for example: MD, DDS, DVM, LLB, JD)
x.
Doctorate degree (for example: PhD, EdD)
5. Which was the primary reason you decide to use the emergency department?
a. My regular doctor is closed right now
b. My regular doctor told me to come to the emergency department
c. The emergency department costs me less money than my usual source of care to resolve my
health issue

INEFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES

32

d. The emergency department takes less time than my usual source of care to resolve my health
issue
e. The wait time in the ED is shorter than the wait time at my usual source of care
f. I prefer not to schedule an appointment (I prefer to walk-in and be seen without an
appointment)
g. The ED is more convenient than my usual source of care
h. My problem can only be addressed in a hospital/ emergency department (emergent issue)
i. I had nowhere else to go
j. Not Answered
6. During the past year, how many times have you visited the following places to receive
medical care?
Location
a. An Emergency Department
b. Doctor’s Office
c. Retail Clinic (such as CVS Minute Clinic or
Beuhler’s Quick Clinic)
d. Free Clinic (such as Open M)
e. Other (specify)

Frequency in past 12
months

8. Would the following help you achieve the level of health you want?
a. Access to a primary care physician
b. After-hours options for minor health issues besides the emergency department
c. A nurse to work with one-on-one to help manage health care needs
d. Transportation to get to medical appointments on-time
e. Access to mental or behavioral health services
f. Online appointment scheduling
g. Referral to a specialist (such as pain management)
h. Other (write in)
8. Do you currently have health insurance?

Yes

No

Not Answered

No

Not Answered

9. If yes, what kind of health insurance do you have?
a. Private insurer (insurance through your (or family member’s) employer, or private
insurance which you have purchased such as Anthem, Medical Mutual of Ohio
(MMO), Aetna, or COBRA)
b. Medicaid
c. Medicare, including Medicare advantage plans
d. Other ________________________________ (write-in)
e. Not Answered

Yes

NA

INEFFECTIVE UTILIZATION OF HEALTHCARE RESOURCES

For the next questions, tell me how you much
agree or disagree with the with the following
statements:
10. How easy was the booklet to read?
11. How easy was it to understand the
information in the booklet?
12. How much did the booklet keep your interest
and attention?
13. How much did you feel you could trust the
information?
14. How good of a method was the teaching
booklet for delivering this intervention?
15. What was the most helpful part of the
booklet?
16. What was the least helpful part of the
booklet?

Very

Mostly

Somewhat

33

Slightly

Not at all

N/A