Literacy demands of product information intended to supplement television direct-to-consumer prescription drug advertisements

Patient Perception and Clinical Impact of Direct-to-Consumer Advertising in Inflammatory Bowel Disease

INTRODUCTION

With an increasing number of available therapies for inflammatory bowel disease (IBD), little is known about patients' attitudes regarding IBD-related direct-to-consumer advertising (IBD-DTCA) and its impact on treatment decisions in clinical practice.

METHODS

We administered a 58-item, mailed questionnaire to patients with IBD receiving Gastroenterology subspecialty care at a large academic health system. The survey assessed patient awareness and perception of IBD-DTCA and its effect on IBD treatment discussions and decisions. We used bivariate analysis to evaluate patient-level factors associated with awareness and favorable perception of IBD-DTCA.

RESULTS

We achieved a response rate of 15.2% (n = 226 of 1486). Most patients (93.3%) reported awareness of IBD-DTCA, with adalimumab receiving the most exposure. A majority of respondents reported IBD-DTCA made them more aware of treatments they otherwise would not know about (53.6%), provided information in a balanced manner (63.5%), and taught them about new potential risks and side effects (64.5%). Patients without a college degree and those with a household income less than $75 k per year perceived IBD-DTCA more favorably. However, IBD-DTCA rarely changed IBD management, with only 7.6% of respondents having a discussion with their provider about the advertised drug and only two (0.9%) being initiated on the advertised drug.

CONCLUSION

IBD patients were aware of IBD-DTCA and perceived it favorably; however, IBD-DTCA rarely led to patient-provider discussions or changes in treatment regimen.

Enhancing the educational value of direct-to-consumer advertising of prescription drugs

OBJECTIVES

The educational value of direct-to-consumer advertising (DTCA) of prescription drugs hinges on its ability to convey important benefit and risk information to consumers. However, the literacy level required to understand some of the information presented in print advertisements may hinder DTCA's ability to educate consumers. The objective of this study was to compare the comprehension and retention of benefit and risk information between consumers who viewed an original print DTCA and those who viewed an advertisement modified according to health literacy principles.

DESIGN

An experimental design was used to conduct the study. Participants were randomly assigned to view a modified print advertisement (experimental group) or the original print advertisement (control group) for an antidepressant medication.

SETTING AND PARTICIPANTS

Study participants were recruited from the University of Wisconsin Kidney Clinic.

OUTCOME MEASURES

Ten true-false and 10 multiple-choice questions were developed to assess participants' comprehension and retention of benefit and risk information.

RESULTS

A total of 120 participants were randomized to view either the original or the modified version of the advertisement. Regarding the comprehension and retention of only the benefit information, no significant differences were observed between the 2 groups. Significant differences were observed for comprehension and retention of only the risk information. The experimental group had significantly higher scores in comprehension (U = 1224; P < 0.01) and retention (U = 965; P < 0.01) of the risk information compared with the control group. These differences were also significant in multivariate analyses controlling for extraneous variables that were found to have associations with comprehension and retention of information.

CONCLUSION

Study results demonstrated that the health literacy techniques used to modify the advertisement were successful in enhancing both consumers' comprehension and their retention of information presented in a print DTCA. This was especially apparent for the risk information.

Direct-to-Consumer Promotion of Prescription Drugs on Mobile Devices: Content Analysis

Background

US Food and Drug Administration (FDA) regulations state that any prescription drug promotion that presents drug benefits to consumers must also disclose certain information about the drug’s risks in a similar manner. Nearly three-quarters of all US mobile phone subscribers use a smartphone, and over half report receiving mobile advertisements on their device.

Objective

The objective of this project was to investigate how prescription drugs are being promoted to consumers using mobile technologies. We were particularly interested in the presentation of drug benefits and risks, with regard to presence, placement, and prominence.

Methods

We analyzed a sample of 51 mobile promotional communications and their associated linked landing pages. We assessed the content and format of the mobile communications and landing pages with regard to presentation of drug benefits and risks.

Results

Of the 51 mobile communications we coded, 41% (21/51) were product claim communications (includes the drug name, benefits, and risks), 22% (11/51) were reminder communications (includes drug name only), and 37% (19/51) were help-seeking communications (includes information about the medical condition but not the drug name). Some of the product claim communications (5/21, 24%) required scrolling to see all the benefit information; in contrast, 95% (20/21) required scrolling to see all the risk information. Of the 19 product claim communications that presented both benefits and risks, 95% (18/19) presented benefits before risks and 47% (9/19) used a bigger font for benefits than for risks. Most mobile communications (35/51, 69%) linked to branded drug websites with both benefits and risks, 25% (13/51) linked to a landing page with benefits but no visible risks, and 6% (3/51) linked to a landing page with risks but no visible benefits. Few landing pages (4/51, 8%) required scrolling to see all the benefit information; in contrast, 51% (26/51) required scrolling to see all the risk information. Of the 35 landing pages with both benefit and risk information, 71% (25/35) presented benefits before risks and 51% (18/35) used a bigger font for benefits than for risks.

Conclusions

These results indicate that, while risks and benefits are both represented in mobile communications and their associated landing pages, they are not equally prominent and accessible. This has implications for compliance with FDA fair balance regulations.

Impact of Animated Spokes-Characters in Print Direct-to-Consumer Prescription Drug Advertising: An Elaboration Likelihood Model Approach

A randomized, posttest-only online survey study of adult U.S. consumers determined the advertising effectiveness (attitude toward ad, brand, company, spokes-characters, attention paid to the ad, drug inquiry intention, and perceived product risk) of animated spokes-characters in print direct-to-consumer (DTC) advertising of prescription drugs and the moderating effects of consumers' involvement. Consumers' responses (n = 490) were recorded for animated versus nonanimated (human) spokes-characters in a fictitious DTC ad. Guided by the elaboration likelihood model, data were analyzed using a 2 (spokes-character type: animated/human) × 2 (involvement: high/low) factorial multivariate analysis of covariance (MANCOVA). The MANCOVA indicated significant main effects of spokes-character type and involvement on the dependent variables after controlling for covariate effects. Of the several ad effectiveness variables, consumers only differed on their attitude toward the spokes-characters between the two spokes-character types (specifically, more favorable attitudes toward the human spokes-character). Apart from perceived product risk, high-involvement consumers reacted more favorably to the remaining ad effectiveness variables compared to the low-involvement consumers, and exhibited significantly stronger drug inquiry intentions during their next doctor visit. Further, the moderating effect of consumers' involvement was not observed (nonsignificant interaction effect between spokes-character type and involvement).

Trends in Urological Direct-to-Consumer Advertising during Prime-Time Television News Programs

INTRODUCTION

The purpose of this study is to characterize contemporary trends in direct-to-consumer advertising of urological pharmaceutical products on American prime-time television programs. Television is the highest expenditure segment of the consumer drug marketing industry. The extent of advertising in urology and its potential impact on patients are not well understood.

METHODS

We retrospectively analyzed an indexed database of prime-time news broadcasts on 5 national networks in the United States. The database was queried with the names of 77 urological pharmaceutical products to identify all commercials that aired during a 36-month period between 2010 and 2013. Noncommercial segments were excluded. Descriptive and linear regression analysis was performed.

RESULTS

We analyzed 4,574 broadcasts, representing 3,067.5 hours of prime-time television. A total of 2,068 commercials for 8 products and 4 urological indications were aired, including sildenafil and tadalafil for erectile dysfunction; 2 testosterone products for hypogonadism; fesoterodine, oxybutynin and solifenacin for overactive bladder; and sipuleucel-T for metastatic castration resistant prostate cancer. Commercials for male oriented indications accounted for 90% of the sample. At least 1 urological advertisement was contained in 1,744 broadcasts (38%). The introduction of television marketing for newly approved testosterone supplementation products in 2012 corresponded to strongly linear growth in overall urological advertising, reaching peak levels in 2013.

CONCLUSIONS

Urological pharmaceutical products have been consistently advertised on television. Commercials have extensively targeted male oriented indications. Viewers of national news programs were exposed to urological advertising during about 40% of broadcasts with steadily increasing exposure since 2012. Providers should be aware of these trends to contextualize demand and monitor prescribing patterns.

Visual elements in direct-to-consumer advertising: Messages communicated to patients with arthritis

Direct-to-consumer (DTC) advertising saturates popular health magazines, communicating persuasive messages to readers that may influence attitudes and behaviors. This research used a two-prong approach to investigate the visual elements used in DTC advertising and their influence on consumers' understanding of a disease and its treatment options. An analysis was conducted of DTC advertisements (N = 62) from a population sample of Arthritis Today magazine, 2000-2010. Three panels of people with arthritis were used to validate the findings and discuss implications for health literacy. Pharmaceutical companies have an opportunity to communicate tailored messages to readers of niche publications and improve disease management.

Medication Safety: Effect of Content and Format of Prescription Drug Labels on Readability, Understanding, and Medication Use: A Systematic Review

Objective:

To evaluate the evidence regarding the optimal content and format of prescription labels that might improve readability, understanding, and medication use.

Data Sources:

We performed a systematic review of randomized controlled trials, observational studies, and systematic reviews from MEDLINE and the Cochrane Database (1990–June 2005), supplemented by reference mining and reference lists from a technical expert panel.

Study Selection:

We selected studies that focused on the content of physician–patient communication about medications and the content and format of prescription drug iabels.

Data Extraction:

Two reviewers extracted and synthesized information about study design, populations, and outcomes,

Data Synthesis:

Of 2009 articles screened, 36 that addressed the content of physician–patient communication about medications and 69 that were related to the content or format of medication labels met review criteria. Findings showed that patients request information about a drug's indication, expected benefits, duration of therapy, and a thorough list of potential adverse effects. The evidence about label format supports the use of larger fonts, lists, headers, and white space, using simple language and logical organization to improve readability and comprehension. Evidence was not sufficient to support the use of pictographic icons. Little evidence linked label design or content to measurable health outcomes, adherence, or safety.

Conclusions:

Evidence suggests that specific content and format of prescription drug labels facilitate communication with and comprehension by patients. Efforts to improve the labels should be guided by such evidence, although additional study assessing the influence of label design on medication-taking behavior and health outcomes is needed. Several policy options exist to require minimal standards to optimize medical therapy, particularly in light of the new Medicare prescription drug benefit.

A Study of the Frequency and Social Determinants of Exposure to Cancer-Related Direct-to-Consumer Advertising Among Breast, Prostate, and Colorectal Cancer Patients

Cancer-related direct-to-consumer advertising (DTCA) is controversial because cancer treatment is complex and entails more risks and costs than typical treatments that are advertised for other conditions. Drawing from the Structural Influence Model of Communication, this study explores communication inequalities in DTCA exposure across social determinants among a population-based sample of 2013 patients diagnosed with breast, prostate, or colorectal cancers. Three survey items assessed patients' frequency of encountering ads concerning treatment alternatives for cancer, dealing with side effects of treatment, and doctors or hospitals offering services for cancer following their diagnosis. The analysis showed that overall exposure to DTCA in this study population was modest (median was once per week). Breast cancer patients reported significantly higher exposure to all three ad categories and overall DTCA exposure than prostate and colorectal cancer patients. Older patients consistently reported lower overall exposure to DTCA across the three cancer types. Other significant correlates included ethnicity (higher exposures among African American prostate cancer patients vs. White; lower exposures in Hispanic colorectal cancer patients vs. White) and cancer stage (higher exposures in Stage IV prostate cancer patients vs. Stages 0-II). Education level did not predict patients' DTCA exposure. The implications of these observed inequalities in DTCA exposure on cancer outcomes are discussed.

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

Background

Significant knowledge gaps exist related to evaluating health product risk communication effectiveness in a regulatory setting. To this end, Health Canada is assessing methods to evaluate the effectiveness of their health product risk communications in an attempt to identify best practices.

Objective

We examined the health literacy burden of Public Advisories (PAs) before and after implementation of a new template. We also compared two methods for their usefulness and applicability in a regulatory setting.

Methods

Suitability assessment of materials (SAM) and readability tests were run by three independent evaluators on 46 PAs (14 “Pre-format change” and 32 “Post-format change”). These tests provided adequacy scores for various health literacy elements and corresponding scholastic grades.

Results

PAs using the new template scored better, with an average increase of 18 percentage points (p < 0.001), on the SAM test. All of the 46 PAs evaluated were rated as “requiring a college/university education comprehension level” using readability tests. Results among readability tests were comparable.

Conclusion

Improvements made to Health Canada’s PA template had a measurable, positive effect on reducing the health literacy burden, based on the SAM results. A greater focus on the use of plain language would likely add to this effect. The SAM test emerged as a robust, reliable, and informative health literacy tool to assess risk messages and identify further improvement efforts. Regulators, industry, and public sector organizations involved in communicating health product risk information should consider the use of this test as a best practice to evaluate health literacy burden.

Electronic supplementary material

The online version of this article (doi:10.1007/s40264-013-0117-8) contains supplementary material, which is available to authorized users.

Direct-to-consumer (DTC) antidepressant advertising and consumer misperceptions about the chemical imbalance theory of depression: the moderating role of skepticism

Based on a survey with members of an online consumer panel (N= 699), this study revealed that: (a) a substantial percentage of consumers held misperceptions about the chemical imbalance theory of depression; (b) personal and interpersonal experiences with depression positively related to such misperceptions; (c) overall, exposure to direct-to-consumer (DTC) antidepressant advertising did not significantly relate to misperceptions; and (d) DTC exposure magnified misperceptions when consumers were highly trustful of DTC advertising, whereas exposure diluted misperceptions when consumers were highly skeptical. Theoretical and practical implications of the research are discussed, especially in light of the social responsibility of DTC advertising.

DTC drug advertising ethics: laboratory for medical marketing

Purpose

– The aim of this paper is to call for an increased focus on the ethics of direct-to-consumer (DTC) prescription drug advertising. This is important, not only to improve DTC prescription drug advertising, but also to inform DTC advertising of future medical advances.

Design/methodology/approach

– This conceptual paper discusses two examples of medical advances – personal genetic testing services and surgically implanted medical devices – to explain how investigating the research of DTC prescription drug advertising can set the stage for more ethical advertising of future medical advances.

Findings

– Specific issues related to health literacy, at-risk populations impacted by health disparities, and medicalization of issues common to aging relate to the DTC advertising of prescription drugs and other medical advances. Creative approaches to investigating these issues in the context of prescription drug advertising can enrich the debate about drug advertising, but also prepare researchers, policymakers, and consumers for future advertising of new medical developments.

Originality/value

– The value of this paper is its call for increased focus on the ethics of DTC prescription drug advertising, to improve the current marketing environment but also lay the foundation for other healthcare marketing in the future.

Consumers' evaluation of brief summary formats of print direct‐to‐consumer advertisements

Purpose

The paper's aim is to measure the effect of various brief summary formats on consumers' drug‐related knowledge, evaluations of ad information, ad believability, attitudes towards the ad and brand, perceived product risk and intention to use ad information in making healthcare decisions.

Design/methodology/approach

Using mall‐intercept surveys, 307 US women, age 18‐50 years, were randomly assigned to one of the six different versions of brief summary formats for a birth control medicine. The six brief summary formats included: no brief summary, traditional (continuous prose) brief summary, risk information window, bulleted list, nutrition facts panel, and question‐answer format. The participants completed a closed‐ended questionnaire after reviewing the print ad.

Findings

MANOVA indicated presence of a multivariate main effect. However, univariate ANOVAs, performed to evaluate the effect of individual formats, revealed that the eight outcome variables did not vary significantly across the six brief summary formats. Nevertheless, respondents exhibited more positive evaluation of the newer brief summary formats compared to the traditional brief summary format, albeit there was no statistically significant difference among the newer formats.

Practical implications

Consumers clearly prefer newer brief summary formats to the traditional brief summary format.

Originality/value

This research provides additional insights about risk communication in direct‐to‐consumer ads and may assist the FDA in the development of a standardized regulatory structure for the future. Providing brief summary in a clearer, understandable, and consumer‐friendly manner can help consumers in deciding whether the drug is appropriate for their condition.

Direct-to-consumer antidepressant advertising and consumers' optimistic bias about the future risk of depression: the moderating role of advertising skepticism

Although exposure to direct-to-consumer prescription drug advertising (DTCA) is reported to influence the public's beliefs about diseases, no research has investigated how DTCA may affect the extent of consumers' optimistic bias about the future risk of diseases. Based on a survey with members of an online consumer panel (n = 699), the current study revealed that: (a) Consumers exhibited a tendency to believe they were at less risk of developing clinical depression in the future than their peers, demonstrating an optimistic bias. (b) Exposure to antidepressant DTCA acted to reduce the extent of such bias, especially when consumers were less skeptical of prescription drug advertising. When consumers were highly skeptical, DTCA exposure did not significantly relate to the extent of optimistic bias. (c) Once formed, the extent of optimistic bias negatively related to consumers' intention to seek information about depression. Implications of the research for the theory and practice of DTCA were discussed.

The politics and strategy of industry self-regulation: the pharmaceutical industry's principles for ethical direct-to-consumer advertising as a deceptive blocking strategy

As the pharmaceutical industry lobbies European regulators to permit direct-to-consumer advertising (DTCA) of prescription drugs in the European Union, we found that five leading companies violated industry-developed and -promulgated standards for ethical advertising in the United States. Utilizing multiple data sources and methods, we demonstrate a consistent failure by companies that market erectile dysfunction drugs to comply with the industry's guiding principles for ethical DTCA over a four-year period despite pledges of compliance by company leaders. Noncompliance resulted in children being exposed to sexually themed promotional messages more than 100 billion times. We argue that the guidelines are a coordinated effort by the industry to prevent unwanted federal regulation, and we introduce the concept of a blocking strategy to explain company behavior and to advance theoretical understanding of firms' public affairs strategies. We recommend policy responses to prevent deceptive practices, protect children from adult content, and promote genuine health care education.

Pharmacy students' opinions of direct-to-consumer advertising: a pilot study at one university

BACKGROUND

Direct-to-consumer advertisement (DTCA) of prescription medications has become an important informational source for health care consumers. As future health care professionals on the front line of potential communication and dispensing of products emerging from DTCA, it is important to elicit the attitudes of student-pharmacists.

OBJECTIVES

This study aims to (1) evaluate the validity of the DTCA attitudinal questionnaire using Rasch rating scale analysis and (2) investigate the attitudes of pharmacy students toward DTCA and determine whether these attitudes were associated with years of pharmacy education and demographic characteristics.

METHODS

This investigation used a cross-sectional print-based questionnaire to evaluate the attitudes of pharmacy students toward DTCA of prescription medications. The 16-item questionnaire included items addressing the attitudes of pharmacy students toward DTCA with respect to patients' knowledge of medications, pharmacists' interaction with patients, and overall consumer judgment of medical prescriptions. Analyses included Rasch analysis and a multiple linear regression.

RESULTS

A total of 243 students submitted usable questionnaires (85% response rate). Item response categories were collapsed from 5 categories to 3, and 4 items were removed to achieve acceptable Rasch model fit. Pharmacy students demonstrated little difficulty in agreeing with the statements suggesting that DTCA helps patients take a more active role in health care and had the most difficulty in agreeing with items suggesting that DTCA may lead to inappropriate prescribing to satisfy patient requests. Students' overall support for DTCA was the only variable that predicted the questionnaire score (P<.001).

CONCLUSIONS

In conclusion, the Rasch analysis evaluated the psychometric properties of the instrument and identified the necessity to adapt the questionnaire from previous iterations to adequately fit the student population. Future research should examine factors that contribute to the variance in attitudes toward DTCA among a larger and more heterogeneous population.

Contribution of communication inequalities to disparities in human papillomavirus vaccine awareness and knowledge

OBJECTIVES

We examined the association of Internet-related communication inequalities on human papillomavirus (HPV) vaccine awareness and infection knowledge.

METHODS

We drew data from National Cancer Institute's 2007 Health Information National Trends Survey (n = 7674). We estimated multivariable logistic regression models to assess Internet use and Internet health information seeking on HPV vaccine awareness and infection knowledge.

RESULTS

Non-Internet users, compared with general Internet users, had significantly lower odds of being aware of the HPV vaccine (odds ratio [OR] = 0.42; 95% confidence interval [CI] = 0.34, 0.51) and knowing that HPV causes cervical cancer (OR = 0.70; 95% CI = 0.52, 0.95). Among general health information seekers, non-Internet seekers compared with Internet information seekers exhibit significantly lower odds of HPV vaccine awareness (OR = 0.59; 95% CI = 0.46, 0.75), and of knowing about the link between HPV infection and cervical cancer (OR = 0.79; 95% CI = 0.63, 0.99) and the sexual transmission of HPV (OR = 0.71; 95% CI = 0.57, 0.89). Among cancer information seekers, there were no differences in outcomes between Internet seekers and non-Internet seekers.

CONCLUSIONS

Use of a communication channel, such as the Internet, whose use is already socially and racially patterned, may widen observed disparities in vaccine completion rates.

Health Literacy INDEX: development, reliability, and validity of a new tool for evaluating the health literacy demands of health information materials

There is no consensus on how best to assess the health literacy demands of health information materials. Comprehensive, reliable, and valid assessment tools are needed. The authors report on the development, refinement, and testing of Health Literacy INDEX, a new tool reflecting empirical evidence and best practices. INDEX is comprised of 63 indicators organized into 10 criteria: plain language, clear purpose, supporting graphics, user involvement, skill-based learning, audience appropriateness, user instruction, development details, evaluation methods, and strength of evidence. In a sample of 100 materials, intercoder agreement was high: 90% or better for 52% of indicators, and above 80% for nearly all others. Overall scores generated by INDEX were highly correlated with average ratings from 12 health literacy experts (r = 0.89, p < .0001). Additional research is warranted to examine the association between evaluation ratings generated by INDEX and individual understanding, behaviors, and improved health. Health Literacy INDEX is a comprehensive tool with evidence for reliability and validity that can be used to evaluate the health literacy demands of health information materials. Although improvement in health information materials is just one aspect of mitigating the effects of limited health literacy on health outcomes, it is an essential step toward a more health literate public.

Health literacy knowledge among direct-to-consumer pharmaceutical advertising professionals

While direct-to-consumer (DTC) prescription drug advertising has been the subject of ongoing debate, to this point the perspective of the advertising professionals engaged in creating these ads has been absent from the discussion. This study, consisting of in-depth interviews with advertising professionals (N = 22), was an initial investigation focused on these individuals. The primary purpose of this study was to explore advertising professionals' understanding of health literacy-consumers' ability to obtain, process, and act on health information; with that context in place, participants' views on the role of DTC advertising, industry regulations, and the future of the industry were also investigated. While some participants knew nothing about health literacy or had a relatively simple conceptualization (e.g., grade level of written materials), others exhibited more nuanced understanding of health literacy (e.g., the need to pair relevant images with text to enhance understanding). Participants spoke of the potential public health benefit of DTC advertising in educating consumers about health issues, but were realistic that such efforts on the part of pharmaceutical companies were driven primarily by business concerns-educational messages need to be tied directly to an advertised medication and its benefits. These professionals spoke of industry regulations as presenting additional barriers to effective communication and suggested that industry trends toward more niche products will necessitate more patient education about less well-known health issues. Directions for future research are considered, as more investigation of this understudied group is necessary to enrich the DTC prescription drug advertising debate.

Cancer-related direct-to-consumer advertising: a critical review

The direct-to-consumer advertising (DTCA) phenomenon has received attention because of its attempt to reach out to consumers by bypassing important gatekeepers such as physicians. The emergence of new information platforms and the introduction of genetic tests directly to the consumer have heightened the concern with DTCA and its potential consequences. These effects of DTCA are particularly important given the communication inequalities among social groups, with class, race and ethnicity influencing how people access, seek, process and act on information. This Science and Society article reviews the major issues regarding general and cancer-related DTCA and also offers data from a national survey in the United States as an example of the communication inequalities in genetic testing awareness.

Journalism as health education: media coverage of a nonbranded pharma web site

OBJECTIVE

As healthcare consumers increasingly use the Internet as a source for health information, direct-to-consumer (DTC) prescription drug advertising online merits additional attention. The purpose of this research was to investigate media coverage of the joint marketing program linking the movie Happy Feet and the nonbranded disease education Web site FluFacts-a resource from Tamiflu flu treatment manufacturer Roche Laboratories Inc.

MATERIALS AND METHODS

Twenty-nine articles (n = 29) were found covering the Happy Feet-FluFacts marketing campaign. A coding guide was developed to assess elements of the articles, including those common in the sample and information that ideally would be included in these articles. Two coders independently coded the articles, achieving intercoder agreement of κ = 0.98 before resolving disagreements to arrive at a final dataset.

RESULTS

The majority of articles reported that Roche operated FluFacts (51.7%) and mentioned the product Tamiflu (58.6%). Almost half (48.3%) reported FluFacts was an educational resource; yet, no articles mentioned other antiviral medications or nonmedical options for preventing the flu. Almost a quarter of the articles (24.1%) provided a call to action-telling readers to visit FluFacts or providing a link for them to do so.

CONCLUSIONS

Findings suggest that journalists' coverage of this novel campaign-likely one of the goals of the campaign-helped spread the message of the Happy Feet-FluFacts relationship, often omitting other useful health information. Additional research is needed to better understand online DTC campaigns and how consumers react to these campaigns and resulting media coverage and to inform the policymakers' decisions regarding DTC advertising online.

A decade of controversy: balancing policy with evidence in the regulation of prescription drug advertising

Direct-to-consumer advertising (DTCA) of prescription drugs has remained controversial since regulations were liberalized by the Food and Drug Administration in 1997. We reviewed empirical evidence addressing the claims made in the policy debate for and against DTCA. This advertising has some benefits, but significant risks are evident as well, magnified by the prominence of DTCA in population-level health communications. To minimize potential harm and maximize the benefits of DTCA for population health, the quality and quantity of information should be improved to enable consumers to better self-identify whether treatment is indicated, more realistically appraise the benefits, and better attend to the risks associated with prescription drugs. We propose guidelines for improving the utility of prescription drug advertising.

Literacy assessment of family health history tools for public health prevention

OBJECTIVES

This study aimed to systematically identify and evaluate the readability and document complexity of currently available family history tools for the general public.

METHODS

Three steps were undertaken to identify family history tools for evaluation: (a) Internet searches, (b) expert consultation, and (c) literature searches. Tools identified were assessed for readability using the Simple Measure of Gobbledygook (SMOG) readability formula. The complexity of documents (i.e., forms collecting family history information) was assessed using the PMOSE/IKIRSCH document readability formula.

RESULTS

A total of 78 tools were identified, 47 of which met the criteria for inclusion. SMOG reading grade levels for multimedia-based tools ranged from 10.1 to 18.3, with an average score of 13.6. For print-based tools, SMOG ranged from 8.7 to 14.1, with an average score of 12.0. Document complexity ranged from very low complexity (level 1 proficiency) to high complexity (level 4 proficiency).

CONCLUSION

The majority of tools are written at a reading grade level that is beyond the 8th grade average reading level in the United States. The lack of family history tools that are easy to read or use may compromise their potential effectiveness in identifying individuals at increased risk for chronic diseases in the general population.

Assessing the scientific accuracy, readability, and cultural appropriateness of a culturally targeted smoking cessation program for American Indians

This study assesses educational materials developed for the All Nations Breath of Life smoking cessation program (targeted for American Indians and Alaska Natives) for scientific accuracy, readability and other literacy factors, and cultural appropriateness. The authors used a scientific review panel of experts in smoking cessation representing epidemiology, medicine, and psychology; the suitability assessment of materials (SAM) and the simplified measure of gobbledygook (SMOG) reading grade level formulas; and review by Native program facilitators and pilot participants. Materials were scientifically accurate and culturally appropriate. The mean SAM score was 80% (superior rating), and the average reading grade level was 7.1 using the Fry formula (part of the SAM) and 8.4 using the SMOG formula (difference was not statistically significant). Based on this project, the SAM can be used in combination with scientific review and input from community members during formative research to assess and modify educational materials for a targeted population.

Suitability and readability of consumer medical information accompanying prescription medication samples

OBJECTIVE

To examine readability and formatting characteristics of consumer medication information (CMI) accompanying prescription medication samples.

METHODS

We collected the most commonly used prescription medication samples (n=100) from four out-patient clinics at a large teaching hospital in the Southeastern US. Seventeen percent of samples were not pills/tablets and of such diverse nature (e.g., injections, drops, and creams) that there were not enough in any category to draw conclusions. Therefore, our analyses were limited to 83pill/tablet samples, belonging to 11 drug classes (e.g., cardiovascular, and psychiatric). We noted if CMI was present, and if so we assessed it for how instructions were presented, reading level, text size, format/layout, and comprehensibility.

RESULTS

No CMI was present in 39 (46.9%) samples. In 19 (22.9%), CMI was contained in a package insert and in 25 (30.2%) it was printed on the medication package. Average reading difficulty of CMI was at the 10th grade level (range=6-15) using the Fry formula, and text point size was small (mean 9.9+/-2.2 on package inserts and 9.4+/-2.6 when printed on packages).

CONCLUSIONS

Almost half of samples did not include any type of CMI. For those that had CMI, it was often written at a reading difficulty level higher than the average reading skills of American adults, and the format of most CMI was not optimal for comprehensibility. It is likely that many patients do not understand the instructions accompanying medication samples they receive from clinicians.

PRACTICE IMPLICATIONS

Clinicians should be cognizant of the shortcomings of CMI accompanying medication samples and thereby, distribute them to patients with caution. Manufacturers too should consider revising CMI to comply with low-literacy guidelines.

Blood glucose monitor quick reference guides: are they suitable for patients?

BACKGROUND

The purpose of this study was to assess readability and related characteristics of English-language Quick Reference Guides (QRGs) accompanying home blood glucose monitors (HBGMs), including reading grade level, dimensions, text point size, illustrations, and layout features.

METHODS

Using the 2006 Diabetes Forecast Resource Guide, we identified HBGMs currently available in the United States. Reading grade level was calculated using Flesch Reading Ease (FRE). Text point size was determined by measuring the distance from the ascent line to the descent line with a C-Thru (Bloomfield, CT) Ruler. Total number of illustrations per QRG was tallied. Illustration dimensions were measured to the nearest millimeter. We also assessed layout features-derived from the Suitability of Materials Assessment and User-Friendliness Tool-including, font style type, use of white space, sentence structure, language style, limited math skill, focus on "Need to Know," and appropriateness of illustrations.

RESULTS

FRE scores ranged from 5(th) to approximately 13(th) grade, while text point size averaged 9.9 +/- 1.6 (range, 8-12). QRGs averaged 15.8.2 +/- 6.0 (range, 6-25) clear and realistic illustrations, most slightly larger than a quarter. Most QRGs avoided use of specialty fonts (85.7%) and limited information to "Need to Know" (92.9%). All instructions required little math skill; however, ample white space was used in five (35.7%) QRGs.

CONCLUSIONS

HBGM manufacturers should increase the size of QRG fold-outs, thereby allowing for larger text size and illustrations, and increasing the amount of white space. Making these relatively small formatting changes would ensure that all patients with diabetes, particularly those with visual impairments, are able to follow HBGM instructions.

Literacy Demands and Formatting Characteristics of Opioid Contracts in Chronic Nonmalignant Pain Management

Chronic nonmalignant pain affects a significant number of adults, with many requiring opioid medications to manage their symptoms. Although the content of typical opioid contracts (OCs) has been explored, no studies have examined the literacy demands and formatting characteristics of OCs currently used throughout the United States. We evaluated 162 English-language OCs submitted to us by current American Pain Society members residing in the United States. OCs were evaluated for reading grade level and formatting characteristics. The mean readability of OCs was at grade level 13.8 +/- 1.3 (range = 10-17), whereas the average text point size was 11.0 +/- 1.4 (range = 6-16). Active voice was used exclusively in almost half of OCs (n = 79, 48.8%). Most OCs contained not only sophisticated medical language but multisyllable, nonmedical terms and vocabulary not used in typical everyday conversation. Overall, most OCs reviewed presented information at much too high a reading grade level, and with formatting characteristics that probably would make these documents difficult for the average patient to fully comprehend.

PERSPECTIVE

This study indicates that there is a mismatch between the reading demands of most OCs and the actual health literacy skills of American adults. Accordingly, those developing OCs should be cognizant of the actual literacy abilities of their patient population and design and evaluate OCs accordingly.

An exploratory study of older adults' comprehension of printed cancer information: is readability a key factor?

Printed cancer information often is written at or beyond high school reading levels, despite lower average literacy abilities of the public. The objectives of this exploratory study were twofold: (1) to evaluate older adults' comprehension of breast (BC), prostate (PC), and colorectal (CC) cancer information; and (2) to determine if comprehension of BC, PC, and CC information varies according to text readability. Comprehension of printed cancer resources was evaluated with 44 community-dwelling older adults using the Cloze procedure and recall questions. Participants' comprehension scores were compared with Simple Measure of Gobbledegook (SMOG) readability scores (<grade 13 vs. grade 13+). Overall, older adults had satisfactory comprehension of cancer information as measured by Cloze (.86 +/- .01) and recall (.71 +/- .02). For CC information written at grade 13, however, a significant negative correlation between readability and Cloze comprehension was found (r(s) = -.44, SE = .17, p = .019), indicating poorer participant comprehension at higher readability levels. Comprehension of BC or PC information did not vary by readability level. Though readability plays a role in older adults' understanding of cancer information, cancer type and content are also important factors that influence comprehension. Use of plain language is recommended for CC resources.

Development of injury prevention materials for people with low literacy skills

OBJECTIVE

Children living in low income urban environments are at high risk for preventable injuries, which result in thousands of Pediatric Emergency Department (PED) visits every year. The development and evaluation of written injury prevention materials used in a PED-based intervention trial are presented. The purpose is to describe the development of injury prevention materials for people with low literacy skills, and explain literacy and comprehension abilities among a sample of parents from the PED.

METHODS

Materials were developed using rules of plain language and with consideration of the needs of a low literacy population. Materials were assessed using the Flesch-Kincaid and Suitability Assessment of Materials. Literacy and comprehension abilities in a PED sample were tested using the Rapid Estimate of Adult Literacy in Medicine (REALM) and the Cloze.

RESULTS

REALM results for n=59 parents sampled from the PED indicated that 27% (n=16) read below 9th grade reading level. Cloze results demonstrate that materials were appropriate for 71% (n=21) when written for 8th grade reading level and 80% (n=23) when rewritten for 6th grade reading level.

CONCLUSION

Others designing similar interventions can use these methods to develop interventions for low literacy populations.

PRACTICE IMPLICATIONS

When developing injury prevention materials for use with PED populations, health professionals should consider reading ability, reading level, content, and design of materials.

Readability characteristics of consumer medication information for asthma inhalation devices

PURPOSE

Successful control of asthma relies heavily on patient adherence to prescribed inhalation therapies. Many patients are unable to use inhalers correctly and, therefore, do not reap the full therapeutic benefits. The purpose of this study was to assess the readability and related characteristics of Consumer Medication Information (CMI) for all prescription asthma inhalation devices currently available in the United States.

METHODS

We identified all brand-name (n = 18) and generic (n = 2) asthma inhalation devices currently available in the United States. English language CMI was obtained from pharmaceutical manufacturers of each identified product. The CMI from these products was evaluated for readability characteristics, including reading grade level using the Fry formula, text point size, dimensions (length and width), diagrams, and directions.

RESULTS

The mean Fry readability of the CMI was at grade level 8.2 +/- 1.5 (range = 5-11), while the average text point size was 9.2 +/- 2.2 (range = 6-12). The mean length of the pages on which the CMI was printed was 33.7 +/- 21.5 cm, while the average width of pages was 12.9 +/- 9.5 cm. There was an average of 6.2 +/- 3.6 (range = 2-12) illustrations per CMI, while a device overview diagram was included in 14 (70%). Eleven (n = 11) instructions included detailed step-by-step diagrams to supplement directions.

CONCLUSIONS

Overall, most CMI for prescription inhalers is presented with a reading difficulty level, text size, diagrams, and instructions that make it suboptimal for patient education. Prescription inhaler manufacturers should consider revising their CMI to comply with generally accepted guidelines preparing patient education information.

Evaluation of web-based osteoporosis educational materials

BACKGROUND

Many women are unaware of risk factors for and consequences of osteoporosis. Hence, patient education is an essential step in preventing and managing osteoporosis. Unfortunately, numerous studies have demonstrated a mismatch between the reading difficulty of typical patient education materials and the reading ability of many American adults.

METHODS

We examined the readability and quality of web-based information on osteoporosis using the Suitability Assessment of Materials (SAM) and DISCERN instruments. The three most widely used Internet search engines, Google, Yahoo, and MSN, were selected based on popularity according to Nielsen/Net Ratings. The search term osteoporosis was entered to generate the first 30 websites listed by each of the three search engines. Several websites appeared on all three search engines; we identified 27 unique websites.

RESULTS

Overall, 51.9% of materials were rated by the SAM as not suitable. Most materials scored poorly for their reading level (82.6% were rated not suitable), with an average reading level at grade 11.5 +/- 2.8. The mean DISCERN score for overall description of treatment options was 35.7 +/- 18.0, indicating inadequate quality. Most materials had low quality in a number of indicators, including accuracy and biased presentation of information.

CONCLUSIONS

Web-based osteoporosis information is written above the reading ability of most American adults, and much of it lacks adequate quality.

Suitability of written supplemental materials available on the Internet for nonprescription medications

PURPOSE

The suitability, readability, and cultural appropriateness of written supplemental materials available on the Internet for nonprescription medications were examined.

METHODS

We videotaped 48 hours of television programming, recording a total of 152 advertisements highlighting 37 unique nonprescription medications. The supplemental materials corresponding to each advertised medication were downloaded and printed in their entirety from each product-specific Web site. These materials were assessed using the Suitability Assessment of Materials (SAM) instrument. Total SAM scores were grouped as follows: not suitable (0-39%), adequate (40-69%), and superior (70-100%). The Fry readability formula was used to determine the reading grade level for the materials assessed with the SAM instrument.

RESULTS

The mean +/- S.D. SAM score of all materials was 54.9% +/- 0.1% (range, 38-76%). Materials for the majority of drugs (86.5%, n = 32) were rated adequate. Materials for four drugs (10.8%) were rated superior, and the material for one drug was not suitable. While the total SAM scores were adequate for most of the materials evaluated, the majority of materials scored particularly poorly for their reading level (the materials for 81.1% of drugs were not suitable). The materials for 40.9% of drugs used uncommon words.

CONCLUSION

Evaluation of the suitability, readability, and cultural appropriateness of written supplemental materials for nonprescription medications available on manufacturer-sponsored Web sites and intended for consumers or patients revealed that SAM scores were adequate for most of the materials; however, many scored poorly in the areas of reading level and used uncommon words.