Evaluating the health literacy burden of Canada's public advisories: a comparative effectiveness study on clarity and readability

Safety Data Sheets as a Hazard Communication Tool: An Assessment of Suitability and Readability

Background

Safety data sheets (SDSs) are hazard communication materials that accompany chemicals/hazardous products in the workplace. Many SDSs contain dense, technical text, which places considerable comprehension demands on workers, especially those with lower literacy skills. The goal of this study was to assess SDSs for readability, comprehensibility, and suitability (i.e., fit to the target audience).

Methods

The Suitability Assessment of Materials (SAM) tool assessed SDSs for suitability and readability. We then amended the SAM tool to further assess SDSs for comprehensibility factors. Both the original and amended SAM tool were used to score 45 randomly selected SDSs for content, literacy demand, graphics, and layout/typography.

Results

SDSs performed poorly in terms of readability, suitability, and comprehensibility. The mean readability scores were Flesch-Kincaid Grade Level (9.6), Gunning Fog index (11.0), Coleman-Liau index (13.7), and Simple Measure of Gobbledygook index (10.7), all above the recommended reading level. The original SAM graded SDSs as "not suitable" for suitability and readability. When the amended SAM was used, the mean total SAM score increased, but the SDSs were still considered "not suitable" when adding comprehensibility considerations. The amended SAM tool better identified content-related issues specific to SDSs that make it difficult for a reader to understand the material.

Conclusions

In terms of readability, comprehensibility, and suitability, SDSs perform poorly in their primary role as a hazard communication tool, therefore, putting workers at risk. The amended SAM tool could be used when writing SDSs to ensure that the information is more easily understandable for all audiences.

The Readability and Quality of Web-Based Patient Information on Nasopharyngeal Carcinoma: Quantitative Content Analysis

BACKGROUND

Nasopharyngeal carcinoma (NPC) is a rare disease that is strongly associated with exposure to the Epstein-Barr virus and is characterized by the formation of malignant cells in nasopharynx tissues. Early diagnosis of NPC is often difficult owing to the location of initial tumor sites and the nonspecificity of initial symptoms, resulting in a higher frequency of advanced-stage diagnoses and a poorer prognosis. Access to high-quality, readable information could improve the early detection of the disease and provide support to patients during disease management.

OBJECTIVE

This study aims to assess the quality and readability of publicly available web-based information in the English language about NPC, using the most popular search engines.

METHODS

Key terms relevant to NPC were searched across 3 of the most popular internet search engines: Google, Yahoo, and Bing. The top 25 results from each search engine were included in the analysis. Websites that contained text written in languages other than English, required paywall access, targeted medical professionals, or included nontext content were excluded. Readability for each website was assessed using the Flesch Reading Ease score and the Flesch-Kincaid grade level. Website quality was assessed using the Journal of the American Medical Association (JAMA) and DISCERN tools as well as the presence of a Health on the Net Foundation seal.

RESULTS

Overall, 57 suitable websites were included in this study; 26% (15/57) of the websites were academic. The mean JAMA and DISCERN scores of all websites were 2.80 (IQR 3) and 57.60 (IQR 19), respectively, with a median of 3 (IQR 2-4) and 61 (IQR 49-68), respectively. Health care industry websites (n=3) had the highest mean JAMA score of 4 (SD 0). Academic websites (15/57, 26%) had the highest mean DISCERN score of 77.5. The Health on the Net Foundation seal was present on only 1 website, which also achieved a JAMA score of 3 and a DISCERN score of 50. Significant differences were observed between the JAMA score of hospital websites and the scores of industry websites (P=.04), news service websites (P<.048), charity and nongovernmental organization websites (P=.03). Despite being a vital source for patients, general practitioner websites were found to have significantly lower JAMA scores compared with charity websites (P=.05). The overall mean readability scores reflected an average reading age of 14.3 (SD 1.1) years.

CONCLUSIONS

The results of this study suggest an inconsistent and suboptimal quality of information related to NPC on the internet. On average, websites presented readability challenges, as written information about NPC was above the recommended reading level of sixth grade. As such, web-based information requires improvement in both quality and accessibility, and healthcare providers should be selective about information recommended to patients, ensuring they are reliable and readable.

COVID-19 and health literacy: the yell of a silent epidemic amidst the pandemic

The emergence of a new form of Coronavirus (SARS-CoV-2) exposed weaknesses of health services in several countries, with overcrowding of hospitals, and lack of supplies and professionals in combating the disease, which sometimes contributed to the installation of social, political, and economic chaos. The critical situation experienced made the subject widely publicized so that the current pandemic also deals with an information epidemic. However, the data received and transmitted require prior critical analysis of its content, although not everyone is able to make the necessary judgment before using or sharing information, partly due to the lack of adequate health knowledge. Health literacy is a broad and important topic in public health but still globally underestimated, thus considered a silent epidemic. The exponential increase in the number of confirmed cases shows the world population's inadequacy and difficulty in understanding basic prevention guidelines. The COVID-19 pandemic warns of gaps in the health literacy levels of the world population and exposes the need for a comprehensive mapping to identify the overall health literacy status in more countries.

Readability and Suitability of COPD Consumer Information

BACKGROUND

Information leaflets have been shown to positively or negatively impact adherence, depending on their content. The objective of this study was to perform an appraisal of the consumer information provided in COPD inhaler monographs.

METHODS

COPD inhalers were identified from the Health Canada Drug Product Database. Medication information and instructions for inhaler use were analyzed for readability by seven formulas, with an acceptability threshold of grades 6-8. Three researchers rated suitability using a modified Suitability Assessment of Materials (SAM) tool and assessed leaflets for explicit warnings.

RESULTS

Twenty-six inhalers with a COPD indication were evaluated. Medication information sections were rated as "difficult to read" or "hard," and 85% (22/26) had a reading level above grade 8. The instructions for inhaler use were rated as "easy" or "fairly easy" to read and 63% (16/26) met the threshold by all formulas. While all leaflets achieved superior suitability ratings, extreme warnings included risk of premature death (n = 12), risks of serious injury (n = 26), serious interactions (n = 26), and statements that convey a serious consequence to therapy (n = 26).

CONCLUSION

While COPD information leaflets in Canada performed well in terms of readability and suitability, overemphasis on side effects, warnings, and precautions may contribute to patient fear and nonadherence.

Online Health Information Regarding Male Infertility: An Evaluation of Readability, Suitability, and Quality

BACKGROUND

Many men lack knowledge about male infertility, and this may have consequences for their reproductive and general health. Men may prefer to seek health information online, but these sources of information vary in quality.

OBJECTIVE

The objective of this study is to determine if online sources of information regarding male infertility are readable, suitable, and of appropriate quality for Internet users in the general population.

METHODS

This study used a cross-sectional design to evaluate online sources resulting from search engine queries. The following categories of websites were considered: (1) Canadian fertility clinics, (2) North American organizations related to fertility, and (3) the first 20 results of Google searches using the terms "male infertility" and "male fertility preservation" set to the search locations worldwide, English Canada, and French Canada. Websites that met inclusion criteria (N=85) were assessed using readability indices, the Suitability Assessment of Materials (SAM), and the DISCERN tool. The associations between website affiliation (government, university/medical, non-profit organization, commercial/corporate, private practice) and Google placement to readability, suitability, and quality were also examined.

RESULTS

None of the sampled websites met recommended levels of readability. Across all websites, the mean SAM score for suitability was 45.37% (SD 11.21), or "adequate", while the DISCERN mean score for quality was 43.19 (SD 10.46) or "fair". Websites that placed higher in Google obtained a higher overall score for quality with an r (58) value of -.328 and a P value of .012, but this position was not related to readability or suitability. In addition, 20% of fertility clinic websites did not include fertility information for men.

CONCLUSIONS

There is a lack of high quality online sources of information on male fertility. Many websites target their information to women, or fail to meet established readability criteria for the general population. Since men may prefer to seek health information online, it is important that health care professionals develop high quality sources of information on male fertility for the general population.

Consumer Understanding, Preferences, and Responses to Different Versions of Drug Safety Messages in the United States: A Randomized Controlled Trial

INTRODUCTION

As part of its mission, the US Food and Drug Administration (FDA) communicates with the public regularly about the benefits and risks of prescription and over-the-counter (OTC) drugs. Effectively communicating risk, however, is a significant public health challenge.

OBJECTIVE

To better understand how different populations understand information communicated by the FDA about drug safety, we conducted a randomized experiment to examine comprehension and other measures of effectiveness of drug safety messages that occurred in a post-market surveillance phase.

METHODS

We used an Internet panel survey of 1244 consumers, of whom 58% used prescription drugs in the past year. Half of the sample panel was randomized to read a previous FDA Drug Safety Communication (DSC) with the drug name changed, and the other half was randomized to read a revised version of the same DSC. We examined how making certain modifications to the way drug risk information is communicated has an impact on comprehension and behavioral intentions, including the user's likelihood of discontinuing the drug. We also studied how comprehension varied by respondent characteristics, health literacy skills, risk perceptions, and trust in the message.

RESULTS

Based on a five-item comprehension index, the revised version of the message was associated with significantly greater comprehension of the information relative to the standard version (63 vs 52% correct, p < 0.001). Significantly more respondents found the revised version to be clear (82 vs 73%, p < 0.000), while fewer in that group reported learning something new (78% vs 84%, p = 0.015). No significant differences emerged between the two groups in terms of the message being informative, convincing, or helpful. We found no significant differences between the two groups in terms of behavioral intentions, risk perception, and trust.

CONCLUSIONS

We found that making plain language changes to the DSC significantly increased consumers' level of comprehension of its content, providing support for ongoing use and further exploration of these strategies in pharmacovigilance communication research. The study findings have important implications for future drug safety and other communication messages related to prescription drugs.

Graphical content of medicinal package inserts: an exploratory study to evaluate potential legibility issues

BACKGROUND

The graphical content of the Medicines Package Inserts (MPIs), such as illustrations and typographic features should be legible and appropriate, as required by international pharmaceutical regulations.

OBJECTIVES

To study: (1) the frequency and type of MPIs' key graphic elements, (2) their compliance with regulations and (3) how educated people understand them.

METHODS

Descriptive study: characterisation of the graphical content of 651 MPIs. Usability study: illustrations and tables (purposively selected) were evaluated with questionnaires in three groups of humanities undergraduates (illustrations only, illustrations plus text and text only).

RESULTS

Descriptive study: illustrations and tables were respectively identified in 6.3% and 11.8% of the MPIs. The illustrations were mainly related to how to take/use the medicine. Non-recommended graphical representations were found (e.g. italic or underline). Usability test: legibility issues were identified, especially for the group of isolated illustrations.

DISCUSSION & CONCLUSIONS

The scarce use of illustrations and tables possibly affected the legibility of the MPIs. Compulsory legibility tests are needed to guarantee the MPIs' proper use, thus contributing to a safe use of medicines. Overall, this study highlighted the need to carefully revise/assess the MPIs' design and probably increase health information experts' awareness on this issue.

Focus on Health Literacy: Recommendations to Improve European Union Risk Management Plan Public Summaries

BACKGROUND

The complexity of drug risk information often exceeds patients' abilities to understand and effectively act on it.

METHODS

The authors evaluated a layperson-focused European Union Risk Management Plan Public Summary and revised it to improve its understandability and usability by applying health literacy principles. The Suitability Assessment of Materials was used to test the appropriateness of the document for readers with low-to-average literacy levels. Two rounds of usability tests were conducted with American adults who had low to average education levels to identify areas of confusion. Revisions were made within perceived regulatory constraints.

RESULTS

A number of health literacy principles can be applied to improve the understandability and usability of the document; however, the document contains many inherently complex concepts.

CONCLUSIONS

The authors recommend that stakeholders reassess the intended use of the document by members of the public and rethink its scope and structure, with close involvement of patients and caregivers.