Research| Volume 49, ISSUE 2, P236-243, March 2023

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Using Comic-Based Concussion Discharge Instructions to Address Caregiver Health Literacy in the Emergency Department

Published:January 03, 2023DOI:



      This study compared the effectiveness of comic-based with text-based concussion discharge instructions on improving caregiver knowledge. This study also examined the role of social determinants of health on comprehension instructions.


      This was an observational study of the caregivers of pediatric concussion patients. Caregivers' health literacy and demographics related socioeconomic factors were obtained. After the patients’ evaluation in the emergency department, caregivers were given printed comic-based concussion discharge instructions. Caregivers were contacted 3 days later and tested overall knowledge of discharge instructions’ content. These survey results were compared with historical controls who received text-based instructions.


      A total of 120 participants were recruited, and 86 participants completed follow-up procedures. When comparing the caregivers’ recall ability with a comic-based vs traditional text-based instructions, caregivers with comic-based content were more likely to accurately recall overall discharge instructions (77.5% vs 44%, P < .001), particularly physical rest and activity restrictions (86.5% vs 63%, P < .001). Caregivers also were less likely to misidentify a red flag symptom (7.5% vs 19%, P < .04). Comic-based instructions did not increase recall of cognitive rest instructions or postconcussive symptoms. When examining demographic factors, caregivers who could not recall 3 postconcussive symptoms were more likely to be Hispanic or Black, less likely to be college educated, and more likely to have low health literacy.


      Novel methods should be explored to adequately prepare caregivers for continuing postconcussive care at home. Discharge instructions must be tailored to address caregivers’ baseline health literacy and how caregivers digest and retain information.

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      Tom N. Pham is Assistant Professor, Department of Pediatrics (Emergency Medicine), University of Texas Southwestern, Dallas, TX.


      Andrea K. Morrison is Associate Professor, Department of Pediatrics (Emergency Medicine), Medical College of Wisconsin, Wauwatosa, WI.


      Michael S. Menard is Family Medicine Physician, Aurora Family Medicine, Aurora, OH.


      Deborah Martinez is Registered Nurse, Urgent Care, Children’s Hospital of Wisconsin, Wauwatosa, WI.


      Danny G. Thomas is Professor, Department of Pediatrics (Emergency Medicine), Medical College of Wisconsin, Wauwatosa, WI. ORCID identifier: