Impact of pictograms on medication adherence: A systematic literature review

A call to action [plans] for cyclic vomiting syndrome

Cyclic vomiting syndrome (CVS) is a disorder of gut-brain interaction which has a wide clinical spectrum. Clinical action plans have been developed to address and to facilitate treatment in the setting of complex, chronic medical conditions. The CVS Action Plan was developed to meet the chronic and acute care needs of children and adults with CVS. While this tool has not been tested for clinical efficacy as was shown with action plans for functional constipation, anecdotal and indirect evidence supports its use. The CVS Action Plan has the potential to enhance outcomes by simplifying home management and streamlining disease recognition and acute care in the emergency department.

Guideline Alignment and Medication Concordance in COPD

BACKGROUND

Provider adherence to clinical treatment guidelines in COPD is low. However, for patients to receive guideline-aligned care, providers not only must prescribe guideline-aligned care, but also must communicate that regimen successfully to patients to ensure medication concordance. The rate of medication concordance between patients and providers and its impact on clinical management is unknown in COPD.

RESEARCH QUESTION

To examine rates of guideline alignment and medication concordance and to identify patient-level factors that place patients at risk for these types of poor disease management outcomes.

STUDY DESIGN AND METHODS

This study was a secondary data analysis of the Medication Adherence Research in COPD study (2017-2023). Participants were categorized into 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage. Medication regimens were classified as aligned or nonaligned with 2017 GOLD guidelines. Nonaligned regimens were stratified further into overuse and underuse categories. Medication concordance between provider-reported and participant-reported regimens was determined. Factors associated with guideline alignment and medication concordance were evaluated using logistic regression.

RESULTS

Of 191 participants, 51% of provider-reported regimens were guideline aligned, with 86% of nonaligned regimens reflecting overuse with an inhaled corticosteroid (ICS). Thirty-eight percent of participants reported different regimens than their providers, of which > 80% reflected participants not reporting medications their providers reported prescribing. Participants did not report long-acting muscarinic antagonists and long-acting beta-agonists at similar rates as ICSs. Greater symptom burden and absence of a pulmonologist on the care team were associated with both guideline misalignment and medication discordance. Cognitive impairment and Black race additionally were associated with medication discordance.

INTERPRETATION

Guideline misalignment and medication discordance were common and were driven by overuse of ICSs and unreported medications, respectively. The patient-level factors associated with medication discordance highlight the importance of improving patient-provider communication to improve clinical management in COPD.

Evaluating Medication Day-Supply for Improving Adherence and Clinical Biomarkers of Hemoglobin A1c, Blood Pressure, and Low-Density Lipoprotein

Objectives: To compare a 90-day-supply and a less than 90-day-supply of medication on adherence to refilling prescriptions and clinical biomarkers for hemoglobin A1c (HbA1c), blood pressure (BP), and low-density lipoprotein (LDL). Methods: A retrospective chart review was completed for a cohort of patients prescribed an oral hypoglycemic agent (OHA), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin II receptor blocker (ARB), and/or a statin. Data were categorized into 90-day-supply and less than 90-day-supply and on the minimum value for control determined by the CMS Star Ratings system. Adherence was defined by the Health Plan Quality Improvement Department as ≥ 85% of days covered. Clinical biomarker cutoffs were HbA1c (<9% or ≥ 9%), BP (Systolic BP ≤ 140 mm Hg and >140 mm Hg or Diastolic BP ≥ 90 mm Hg regardless of SBP), and LDL (<100 mg/dl or ≥100 mg/dl). Results: The analysis included 251 patients: 159 females (mean 64.9 ± 11.7 years) and 92 males (mean 61.5 ± 11.3 years). Patients with medications from multiple classes were included in more than one analysis. Adherence was statistically in favor of the 90-day-supply compared to less than 90-day-supply for all three classes of drugs. The clinical biomarkers were statistically not different for each drug group. Conclusion: A 90-day-supply was statistically greater than a less than 90-day-supply for CMS Star Ratings metrics, but was not statistically significant for clinical biomarkers for HbA1c, SBP, and LDL.

Two stroke education programs designed for older adults

Stroke is an important public health problem worldwide and in Korea causing death and serious long-term disability. This study tested the feasibility, acceptability, and preliminary efficacy of two stroke education programs. The pictogram-based education program was administered to 118 participants, and the PowerPoint-based education program was administered to 108 participants. Stroke knowledge (stroke definition, risk factors, warning signs) and first action knowledge in the event of stroke were assessed among all participants prior to and following completion of their respective programs. Both stroke education programs showed similar, significant improvements in stroke knowledge and first action knowledge from baseline to posttest. Also, feasibility (81-88 % participation and 96 % completion) and acceptability (86-97 % satisfaction) of both stroke education programs were supported. These findings indicate that healthcare professionals can use either of the education programs to improve stroke knowledge and first action knowledge among older adults who are at high risk for stroke.

Pharmaceutical indication pictograms for low literacy viewers: Health literacy and comprehension

Background

Poor comprehension of pharmaceutical pictograms used on medicine labels or leaflets can compromise understanding of medicine-taking information, potentially causing negative health outcomes.

Aim

The aim was to assess association of health literacy (HL) with comprehension of pictograms displaying indication and side effect information in a lower literacy, limited English proficiency (LEP) population.

Setting

Community centre, Makhanda, South Africa.

Methods

This was a quantitative cross-sectional study using simple random probability sampling. Ninety isiXhosa-speaking adults with a maximum of 12 years schooling, attending primary healthcare clinics were interviewed using structured interviews. Health literacy was assessed using the Health Literacy Test for Limited Literacy populations. Comprehension of 10 locally developed pictograms was evaluated.

Results

The mean pictogram comprehension score was 7.9/10, with 8/10 pictograms complying with the International Organization for Standardization criterion of 66.7% correct comprehension. Only 15.6% of participants had adequate HL. A significant association of HL with pictogram comprehension was established (p = 0.002). Pictogram misinterpretation was higher in those with lower HL; adequate HL was associated with superior comprehension. Pictogram comprehension was negatively associated with age (p < 0.006), and positively associated with education (p < 0.001) and English proficiency (p < 0.001).

Conclusion

Higher HL was associated with better pictogram comprehension. Low HL, LEP and low education levels are regarded as potential indicators for possible pictogram misinterpretation.

Contribution

This study observed the potential for misinterpretation of medication pictograms. Health professionals should be aware that low HL, limited schooling and limited English proficiency could signal difficulty in fully comprehending pictogram content.

Comprehension of prescription orders with and without pictograms: tool validation and comparative assessment among a sample of participants from a developing country

BACKGROUND

Medication errors can often occur due to the patient's inability to comprehend written or verbal medication orders. This study aimed to develop pictograms of selected medication orders and to validate the comprehension of prescription orders index and compare the comprehension scores with and without pictograms. In addition to determine the predictors that could be associated with a better or worse comprehension of prescription orders with pictograms versus that of their written counterparts.

METHODS

A cross-sectional study was conducted using a snowball sampling technique. Six pictograms were developed to depict specific medication orders. The comprehension of prescription orders index was constructed and validated. The study then compared the comprehension scores of prescription orders with and without pictograms, and identified the predicting factors score difference.

RESULTS

A total of 1848 participants were included in the study. The structure of the comprehension of prescription orders index was validated over a solution of four factors, with an adequate Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy of 0.711 and a significant Bartlett's test of sphericity (P < 0.001). The construct validity of the index was further confirmed by highly significant correlations between each item and the full index (P < 0.001). The study also found a significant association between the difference in comprehension scores for prescription orders with and without pictograms and several factors, including age, level of education, area of residence, number of children, and smoking status with the difference of comprehension scores (P < 0.001).

CONCLUSION

Pictogram-based instructions of medication orders were better understood by the Lebanese population than written instructions, making the incorporation of pictograms in pharmacy practice paramount to optimize medication use by the patient and thus yielding better health outcomes.

Patient satisfaction survey of the "Healthy Heart" pharmaceutical care service - evaluation of pharmacy labelling with pharmaceutical pictograms

INTRODUCTION

Low adherence is a major challenge in healthcare worldwide, being particularly dangerous for patients with chronic diseases, such as cardiovascular diseases and heart failure, where strict adherence is essential. Non-adherence is observed in almost half of patients, and the consequences encompass a lack of therapeutic effects, health deterioration, decreased quality of life, and even death. For cardiovascular patients, the great importance of health education and pharmaceutical education can be provided within pharmaceutical care in community pharmacies. Therefore, our study aimed at evaluating the level of satisfaction with the "Healthy Heart" pharmaceutical service, in which patients received pictograms with dosage information affixed to their medication.

MATERIAL AND METHODS

The study was designed for patients who had been prescribed an antiplatelet medication for the first time. The patients were recruited by 577 pharmacies that took part in the study after completing a special course. Ultimately, 1590 patients were enrolled in the study. The project ran from November 2019 to January 2022.

RESULTS

Most of patients had a positive attitude to the "Healthy Heart" pharmaceutical service. More than 85% of the respondents were of the opinion that the pictograms facilitated the use of the medication, and 81.7% of the respondents stated that the system of labels helped in adherence. Over 66% of the respondents thought that such labels should be included in pharmacy services, and 77.92% of the participants reported that this system of labelling medications should be offered through all pharmacies.

CONCLUSIONS

Pharmaceutical labels in the pharmacists' everyday practice can largely improve patient adherence. These efforts, provided as part of their pharmaceutical services, can have a huge influence on optimisation of patient health outcomes.

Do Pictograms on Medication Packages Cause People to Consult Package Inserts Less Often? If so, With What Consequences?

Overall, pharmaceutical pictograms seem to improve medication adherence. However, little is known about how warning pictograms (e.g., "do not drive after taking") on medication packages influence patients' information-seeking strategies such as consulting the package insert (PI) to determine other features such as the correct dosage. In this online study, participants (358 students) were presented with three fictitious scenarios (e.g., headache after alcohol consumption; factor scenario) in which medication use would be contraindicated. Each scenario was accompanied by a visual presentation of a medication package that could contain three possible pictogram selections or arrangements (factor warning); some arrangements contained pictograms relevant to the situation represented by the scenario, while others did not. Participants had to decide which dosage of the represented medication they were allowed to take in the given scenario. In making this decision, they could consult the PI or not. Overall, in two out of the three scenarios (driving and pregnancy), medication packages with relevant pictograms resulted in fewer PI consultations but led to more correct dosage decisions ("no pill") than packages with irrelevant pictograms. Pictograms generally played no role in either the review of the PI consultation or dosage decisions in the alcohol scenario. Providing warning-relevant pictograms on medication packages can help people know when they should not take medication even without reading the PI.

Icono: a universal language that shows what it says

This article lays out the foundation of a new language for easier written communication that is inherently reader-friendly and inherently international. Words usually consist of strings of sounds or squiggles whose meanings are merely a convention. In Icono, instead, they typically are strings of icons that illustrate what they stand for. "Train," for example, is expressed with the icon of a train, "future" with the icon of a clock surrounded by a clockwise arrow, and "mammal" with the icons of a cow and a mouse-their combination's meaning given by what they have in common. Moreover, Icono reveals sentence structure graphically before, rather than linguistically after, one begins reading. On smartphones and computers, writing icons can now be faster than writing alphabetic words. And using simple pictures as words helps those who struggle with conditions like dyslexia, aphasia, cerebral palsy, and autism with speech impairment. Because learning its pronunciation or phonetic spelling is optional rather than a prerequisite, and because it shows what it says, Icono is bound to be easier to learn to read-and then easier to read-than any other language, including our own.

Methodology of an approach for modifying pictograms showing medication side effects or indication

BACKGROUND

Pictograms may improve user-friendliness and comprehension of written or verbal health information. This paper describes a method to modify pictograms to improve their visual clarity, appeal and overall interpretive complexity in order to reduce the cognitive load on the viewer during comprehension.

METHODOLOGY

Nine pictograms previously tested for comprehension were selected for modification. In phase 1, two participatory design workshops were conducted with (a) three limited literacy, first-language isiXhosa-speaking participants and (b) four university students. Opinions and ideas for improving interpretation were discussed. In phase 2, revised visuals were generated by the graphic artist and subsequently modified in an intensive, multistage, iterative process.

RESULTS

As no guidelines for pictogram modification exist, a modification schema was developed based on the process described in this study. Adopting a participatory approach combined with a systematic, intensive modification process enabled the opinions and preferences of the end-users to be heard, ensuring cultural relevance and contextual familiarity of the final product. Careful scrutiny of all individual visual elements of each pictogram, considerations of space, and thickness of lines all contributed to improving the legibility of visuals.

CONCLUSIONS

The methodology for designing and modifying existing pictograms using a participatory process resulted in nine final pictograms that were approved by all design team members and considered good candidates for subsequent comprehension testing. The methodological schema presented in this paper provides guidance to researchers intending to design or modify pictograms.

Development and acceptability of a decision aid for anxiety disorder considering discontinuation of benzodiazepine anxiolytic

Aim

We aimed to develop a decision aid (DA) for individuals with anxiety disorders who consider tapering benzodiazepine (BZD) anxiolytics, and if tapering, tapering BZD anxiolytics with or without cognitive behavioral therapy (CBT) for anxiety. We also assessed its acceptability among stakeholders.

Methods

First, we conducted a literature review regarding anxiety disorders to determine treatment options. We cited the results of the systematic review and meta-analysis, which we conducted previously, to describe the related outcomes of two options: tapering BZD anxiolytics with CBT and tapering BZD anxiolytics without CBT. Second, we developed a DA prototype in accordance with the International Patient Decision Aid Standards. We carried out a mixed methods survey to assess the acceptability among stakeholders including those with anxiety disorders and healthcare providers.

Results

Our DA provided information such as explanation of anxiety disorders, options of tapering or not tapering BZD anxiolytics (if tapering, the options of tapering BZD anxiolytics with or without CBT) for anxiety disorder, benefits and risks of each option, and a worksheet for value clarification. For patients (n = 21), the DA appeared to be acceptable language (86%), adequate information (81%), and well-balanced presentation (86%). The developed DA was also acceptable for healthcare providers (n = 10).

Conclusion

We successfully created a DA for individuals with anxiety disorders who consider tapering BZD anxiolytics, which was acceptable for both patients and healthcare providers. Our DA was designed to assist patients and healthcare providers to involve decision-making about whether to taper BZD anxiolytics or not.

Development and assessment of a low literacy, pictographic asthma action plan with clinical automation to enhance guideline-concordant care for children with asthma

OBJECTIVE

Asthma is characterized by reversible pulmonary symptoms, frequent hospitalizations, poor quality of life, and varied treatment. Parents with low health literacy (HL) is linked to poor asthma outcomes in children. Recent practice updates recommended inhaled corticosteroids for the management of persistent asthma, but guideline-concordant care is suboptimal. Our aim was to develop and assess an Asthma Action Plan (AAP) that could serve as an individualized plan for low HL families and facilitate guideline-concordant care for clinicians.

METHODS

We followed the National Institute of Health 5-step "Clear & Simple" approach to develop the Uniformed Services AAP. Our AAP included symptom pictographs (dyspnea, cough, sleep, activity) and guideline-concordant clinical automation tools. Caregivers assessed the pictograms for validity (transparency of ≥ 85%; translucency score ≥ 5; and ≥ 85% recall). Readability was assessed using 7 formulas. (<6th Grade was acceptable). Comprehensibility, design quality, and usefulness was assessed by caregivers using the Consumer Information Rating Form (CIRF) (>80% was acceptable). Understandability and actionability was assessed by medical librarians using the Patient Education Materials Assessment Tool-Printable (>80% was acceptable). Suitability was assessed by clinicians using the modified Suitability Assessment of Materials (SAM) instrument (>70% was superior).

RESULTS

All 12 pictograms were validated (N = 118 respondents). Readability demonstrated a 4th grade level. Overall CIRF percentile score = 80.4%. Understandability and Actionability = 100%. Suitability score = 75%.

CONCLUSIONS

Our AAP was formally endorsed by the Allergy & Asthma Network. The Uniformed Services AAP is a novel tool with embedded clinical automation that can address low HL and enhance guideline-concordant care.

Guessability of standard pharmaceutical pictograms in members of the Nigerian public

Background

Pharmaceutical pictograms are standardized images used to visually convey medication instructions. Very little is known about the ability of Africans to interpret these images.

Objectives

Thus, the aim of this study was to assess the guessability (ability to correctly guess meaning) of selected International Pharmaceutical Federation (FIP) and United States Pharmacopoeia (USP) pictograms in members of the Nigerian public.

Methods

A cross-sectional survey was carried out between May and August 2021 on 400 randomly sampled members of Nigerian public. Selected pictograms (24 FIP and 22 USP pictograms) were grouped and printed on A3 sheets of paper which were used to interview members of the public who fulfilled the study's' eligibility criteria. Respondents were asked to guess the meanings of either the FIP or USP pictograms, and their answers written down verbatim. Descriptive and inferential statistics were used to report the data collected.

Results

Four hundred respondents were interviewed, with 200 respondents each assessing the guessability of the FIP and USP pictograms. The guessability of assessed FIP pictograms ranged between 3.5 and 95%, while that for the USP pictograms was 27.5-97%. Eleven FIP and Thirteen USP pictograms respectively achieved the International Organization for Standardization (ISO) comprehensibility cutoff point of 67%. Guessing performance (the total number of pictograms correctly guessed by an individual) of respondents that assessed the FIP pictograms was significantly associated with their age (p = 0.044) and highest level of education completed (p = 0.003). For the USP pictograms, guessing performance was only significantly associated with the highest educational level completed (p < 0.001).

Conclusions

Guessability of both pictogram types varied widely, but the guessability of the USP pictograms was generally better than that for the FIP pictograms. Many of the tested pictograms may however need to be redesigned before they can be correctly interpreted by members of the Nigerian public.

Optimization of Therapy in Patients with Epilepsy and Psychiatric Comorbidities: Key Points

Psychiatric disorder comorbidity in patients with epilepsy (PWE) is very frequent with a mean percentage prevalence of up to 50% and even higher. Such a high frequency suggests that epilepsy and psychiatric disorders might share common pathological pathways. Various aspects contribute in making the matter very complex from a therapeutic point of view. Some antiseizure medications (ASMs), namely valproic acid, carbamazepine, and lamotrigine, have mood-stabilising effects and are routinely used for the treatment of bipolar disorder in patients who do not have epilepsy. Pregabalin and, to a lesser extent, gabapentin, exerts anxiolytic effects. However, several ASMs, in particular levetiracetam, topiramate, and perampanel, may contribute to psychiatric disorders, including depression, aggressive behaviour, and even psychosis. If these ASMs are prescribed, the patient should be monitored closely. A careful selection should be made also with psychotropic drugs. Although most of these can be safely used at therapeutic doses, bupropion, some tricyclic antidepressants, maprotiline, and clozapine may alter seizure threshold and facilitate epileptic seizures. Interactions between ASMs and psychotropic medication may make it difficult to predict individual response. Pharmacokinetic interactions can be assessed with drug monitoring and are consequently much better documented than pharmacodynamic interactions. Another aspect that needs a careful evaluation is patient adherence to treatment. Prevalence of non-adherence in PWE and psychiatric comorbidities is reported to reach values even higher than 70%. A careful evaluation of all these aspects contributes in optimizing therapy with a positive impact on seizure control, psychiatric wellbeing, and quality of life.

Effects of a multidisciplinary management program on symptom burden and medication adherence in heart failure patients with comorbidities: A randomized controlled trial

BACKGROUND

Comorbidities in heart failure (HF) are a complex clinical challenge. There is little data on the benefits of multidisciplinary postdischarge management programs in such patients. This study aimed to examine the effects of a multidisciplinary management program (MMP) on symptom burden and medication adherence in HF patients with comorbidities.

METHODS

In this clinical trial study, 94 HF patients with comorbidities were assigned to intervention (n = 47) and control (n = 47) groups by the stratified-random method. The intervention group underwent MMP supervised by a nurse for two months after discharge, including multi-professional visits, telephone follow-ups, and an educational booklet. Medication adherence and symptom burden were assessed using Morisky Medication Adherence Scale (MMAS) and Edmonton Symptom Assessment Scale (ESAS), respectively, on three occasions: Before discharge, six weeks, and eight weeks after discharge.

RESULTS

Both groups almost matched at the baseline, and the most frequent comorbidities included myocardial infarction (MI), hypertension, peptic ulcer, and depression, respectively. The interactive effect of time in groups showed that mean changes in total scores of symptom burden and medication adherence were significantly different (P < 0.001) at other time points. A significant increase in medication adherence (P < 0.001) and a significant reduction in the burden of all symptoms were observed in the intervention group compared to the control group from Time 1 to Time 3.

CONCLUSIONS

The MMP (targeting comorbidity) is a promising strategy for managing symptoms and medication adherence in HF patients with comorbidities.

Affecting children’s knowledge about rational use of medicines using read-along videos of pictorial storybooks

Although efforts have been taken to educate the public about medication from a very young age, there are very limited availability and accessibility of education material for children. The aim of this study is to assess the impact of read-along videos of pictorial storybooks on children’s knowledge about rational use of medicines. This study compared pre and post knowledge scores in a nonrandomized, one-group pre-test-post-test experimental design. Pre-recorded read-along storytelling videos were used as intervention covering two topics on rational use of medicine -medicine storage and antibiotic resistance. The questionnaire and intervention videos were distributed using Google Forms to children aged six and seven in Malaysia via online social media platforms. 521 children completed the study. The mean baseline knowledge score for medication storage was 4.89 (SD = 1.12) pre-test and 5.44 (SD = 0.78) post-test while for antibiotic resistance the mean was 3.616 (SD = 1.340) pre-test and 4.820 (SD = 1.134) post-test. A Wilcoxon signed-rank test showed statistically significant changes on medication storage (Z = −10.21, p < 0.001) and antibiotic resistance (Z = −14.869, p < 0.001) related knowledge among children. Pictorial storybook read-along video interventions were shown to be effective in improving children’s knowledge on rational use of medicine. Education and awareness on the use of antibiotics should be prioritized.

Evaluation of a pharmacist-led intervention to improve medication adherence in patients initiating dabigatran treatment: a comparison with standard pharmacy practice in Poland

Backround

Dabigatran is a direct thrombin inhibitor used to treat cardiac arrhythmias, and rates of non-adherence to dabigatran in Polish populations are high. The current study examined how a pharmacist-led intervention of counselling with pictogram-enhanced medication instructions, and smartphone medication reminders, can improve adherence to dabigatran.

Methods

A 3-month pharmacist-led intervention was conducted in community pharmacies in Poland on 325 men and women filling a dabigatran prescription for the first time. Participating pharmacies were assigned into the Control Group (n = 172 patients) or the Intervention Group (n = 153 patients). The primary outcome of this prospective study was self-reported medication adherence assessed at 3 time points (day 7, day 21, and day 90) after initiation of dabigatran.

Results

Patients in the Intervention Group were significantly more adherent (mean days on Dabigatan/week) than the Control Group at 7 days (6.0 ± 0.9 vs 5.4 ± 1.1, p < 0.0001), 21 days (5.6 ± 1.0 vs 4.9 ± 1.3, p < 0.0001), and 90 days (5.5 ± 1.3 vs 4.4 ± 2.0, p < 0.0001), respectively. The percentage of patients in the Intervention Group who reported taking dabigatran twice/day as prescribed was significantly higher than the Control Group at 7 days (82.7% vs 71.4%, p = 0.0311), at 21 days (84.4% vs 58%, p < 0.0001), and at 90 days (78.4% vs 39.7%, p < 0.0001), respectively. The proportion of patients fully adherent (every day, twice/day) at 90 days was significantly higher in the Intervention Group than in the Control Group (26.1% vs 13.2%, p = 0.0145).

Conclusions

Our findings support the role for interventions in community pharmacies in Poland to improve medication adherence, thus providing evidence for the efficacy of a pharmacist-led pictogram and smartphone-based program to support optimal dabigatran treatment.

Health literacy characteristics of over-the-counter rapid antigen COVID-19 test materials

Background

The United States Food & Drug Administration's emergency authorized use, in December 2020, of over-the-counter (OTC) rapid antigen COVID-19 tests was a pandemic control milestone.

Objective

To assess health literacy-related characteristics of OTC rapid antigen COVID-19 test materials.

Methods

Between September–December 2021, we identified eleven (n = 11) OTC rapid antigen COVID-19 tests available for purchase in the US. We assessed readability (Flesch Reading Ease and Fernández-Huerta), formatting and layout features of English- and Spanish-language step-by-step OTC rapid antigen COVID-19 test package insert instructions. Video-based step-by-step OTC rapid antigen COVID-19 test instructions were evaluated for understandability and actionability (Patient Education Materials Assessment Tool for Audiovisual Materials [PEMAT-A/V]), overall quality (Global Quality Scale [GQS]) and cultural diversity and inclusiveness. Descriptive analyses were performed using IBM® Statistical Package for the Social Sciences.

Results

Nine (81.8%) OTC rapid antigen COVID-19 tests included English-language (≈8th-9th reading grade level) step-by-step instructions, while 4 included Spanish-language (≈10th-12th reading grade level) instructions. On average, instructions were printed on a tabloid sized piece of paper, with text size ranging from 4 to 12 point and including nearly 20 illustrations. English-language step-by-step OTC rapid antigen COVID-19 test video-based instructions (n = 6) ranged from 1:04 to 5:41 min with PEMAT-A/V scores ranging from 80% to 100%. As indicated by GQS scores, English-language videos were of high quality (5 videos scored 5/5; 1 video scored 4/5). One COVID-19 test product manufacturing website included Spanish-language video-based instructions (time = 4:59 min; PEMAT-A/V = 100%; GQS = 5).

Conclusions

OTC COVID-19 test step-by-step instructions—both package inserts and video-based—included features shown to foster patient understanding and facilitate proper use. Moving forward, greater attention needs to be placed on expanding both Spanish-language and video-based OTC COVID-19 test material availability to improve accessibility across diverse populations.

Clinical action plans make a difference at point-of-care

PURPOSE OF REVIEW

The purpose of this review is to provide an update to and roadmap for the practical implementation of various point-of-care clinical action plans for primary care providers.

RECENT FINDINGS

Clinical action plans were first developed to address unmet, home preventive needs for the management of asthma. Over the past 10 years, the advancement of mobile health technologies, the recognition of at-risk populations, and the development of evidence-based concepts to guide the creation of patient education tools have expanded the implementation of clinical action plans for many diagnoses (e.g., functional constipation, atopic dermatitis, and headache migraines). Poor patient-related clinical outcomes have been linked with low health literacy for many chronic diseases of childhood. This has served as a call to action to improve patient education. Clinical action plans address this gap by facilitating superior knowledge transfer from the medical team in the clinic to the patient/caregiver. The use of clinical action plans can serve as clinical decision support tools for the medical team and has been demonstrated to improve patient adherence to complex therapy regimens.

SUMMARY

Clinical action plans have the potential to improve disease-related self-management confidence, increase pharmacotherapy adherence, and enhance guideline-concordant care. These clinical decision support tools are safe, inexpensive, and represent an advancement in the high-value care model in pediatric medicine.

Development and Assessment of a Low Literacy, Pictographic Cyclic Vomiting Syndrome Action Plan

OBJECTIVE

To develop and assess an evidence-based, individualized Cyclic Vomiting Syndrome Action Plan (CVSAP) to optimize both preventative and acute care.

STUDY DESIGN

This implementation science project synthesized a combination of clinical practice guidelines, published literature, and clinical experience by a team of CVS clinicians to develop the CVSAP. The tool was developed to include validated pictograms and an automatic, embedded, weight-based dosing calculator to output acute management recommendations. The final version of the CVSAP was tested by patients/caregivers, readability calculators, medical librarians, and clinicians using validated metrics.

RESULTS

All pictograms met the criteria for inclusion in the CVSAP. A composite readability score of 5.32 was consistent with a fifth-grade level. Patients/caregivers (n = 70) judged the CVSAP to be of high quality with consumer information rating form rating of 84.2%. Six medical librarians rated the CVSAP to have 93% understandability and 100% actionability, and 33 clinicians completing the SAM generated a suitability rating of 87.5%.

CONCLUSIONS

The CVSAP visually highlights individualized care plan components to facilitate optimized preventative and acute CVS care. Further investigation will determine if CVSAP increases caregiver confidence and compliance in home management and improves quality of life and clinical outcomes for patients with CVS.

The impact of using pictorial aids in caregivers’ understanding of patient information leaflets of pediatric pain medications: A quasi-experimental study

Introduction

Patient information leaflets (PILs) are one of the main sources of information for over-the-counter medications (OTCs). This study aimed to assess caregivers' understanding of instructions in PILs provided with paracetamol medications and the impact of pictograms use.

Methods

A quasi-experimental study was conducted among caregivers of children aged < 13 years recruited in pediatric outpatient clinics at University Medical City in Riyadh. The calculated sample size was 128; at least 64 participants were needed in each group (the text-only group and the text-plus pictograms group). Caregivers' health literacy was assessed using a validated Arabic version of the Newest Vital Sign scale. Participants’ understanding of PILs instructions was assessed using eight questions on the route of administration, minimal hours between doses, max daily dose, shake medication before use, storage, and reporting adverse events; and was rated based on the number of questions correctly understood. Characteristics of participants were compared by Pearson X² and t-test was used to assess the significance of mean score differences between groups.

Results

A total of 130 caregivers participated in the study; almost half of them were mothers (47%, [n = 61]) and 43% (n = 56) have “a possibility of limited health literacy”. The mean number of correct answers to questions assessing the understanding of PILs instructions was significantly higher among the text-plus pictograms group compared to the text-only group (5.25 ± 1.85 vs. 4.38 ± 1.27; p < 0.001). When results were controlled for age and gender, better health literacy was found to be associated with a better understanding of instructions (B = 0.39, 95 %CI 0.23–0.54).

Conclusion

Limited comprehension of medications instructions was observed; adding pictorial aids to PILs might enhance the comprehension. Differences in health literacy levels of caregivers should be considered when designing PILs.

Development and assessment of a low-health-literacy, pictographic adrenal insufficiency action plan

OBJECTIVES

Adrenal insufficiency (AI) is an overall rare disorder characterized by the chronic need for pharmacotherapy to prevent threat to life. The Pediatric Endocrine Society has recommended the use of clinical action tools to improve patient education and help guide acute management of AI. We aimed to develop and assess an easy-to-use, patient-friendly, evidence-based, personalized pictogram-based adrenal insufficiency action plan (AIAP) to aid in the management of AI in children.

METHODS

Patients/caregivers (P/Cs) responded to surveys which measured the concepts of transparency, translucency, and recall in order to assess the pictograms. Readability was assessed using six formulas to generate a composite readability score. Quality was graded by P/Cs using the Consumer Information Rating Form (CIRF) (>80% rating considered acceptable). Understandability and actionability was assessed by medical librarians using the Patient Education Materials Assessment Tool-Printable (PEMAT-P) (>80% rating was acceptable). Suitability was evaluated by clinicians using the Suitability Assessment of Materials (SAM) instrument (>70% rating considered superior).

RESULTS

All pictograms met criteria for inclusion in the AIAP. Composite readability score=5.4 was consistent with a fifth-grade level. P/Cs (n=120) judged the AIAP to be of high quality with CIRF rating=85.2%. Three medical librarians rated the AIAP to have 100% understandability and 100% actionability. Thirty-three clinicians completing the SAM generated a suitability rating of 90.0%.

CONCLUSIONS

The AIAP visually highlights individualized care plan components to facilitate optimized preventative and acute AI care. Further investigation will determine if AIAP improves clinical outcomes for patients with AI.

Development and acceptability of a decision aid for chronic insomnia considering discontinuation of benzodiazepine hypnotics

Aim

To describe the development and acceptability of a decision aid (DA) for chronic insomnia considering discontinuation of benzodiazepine (BZD) and benzodiazepine receptor agonist (BZRA) hypnotics, and if discontinuing, tapering with or without cognitive behavioral therapy for insomnia (CBT‐I).

Methods

We reviewed relevant literature describing chronic insomnia to identify options. We used the results of the systematic review and meta‐analysis conducted previously to determine the related outcomes of two options: discontinuation of BZD/BZRA hypnotics by gradual tapering alone and discontinuation of BZD/BZRA hypnotics by gradual tapering with CBT‐I. We then developed a prototype of DA following the International Patient Decision Aid Standards. A mixed methods survey was conducted to assess the acceptability among patients and healthcare providers.

Results

The prototype consisted of a description of insomnia, options of continuing or discontinuing BZD/BRZA hypnotics (if discontinuing, the options of tapering hypnotics with or without CBT‐I), pros and cons of each option, and a value clarification exercise. Patients (n = 24) reported that the DA had acceptable language (79%), adequate information (71%), and well‐balanced presentation (91%). Healthcare providers (n = 20) also provided favorable feedback.

Conclusion

We developed a DA for chronic insomnia considering discontinuation of BZD/BRZA hypnotics, which was acceptable for stakeholders. The developed DA was designed to support patients and healthcare providers to make a decision about whether to discontinue BZD/BRZA hypnotics.

Medication Adherence and the Role of Pictograms in Medication Counselling of Chronic Patients: a Review

Pharmaceutical care requires a patient-centered approach, focusing on the ability of patients to understand drug-related information and follow the instructions delivered by pharmacists as well as other health-care providers included in the circle of care. With the goal of ensuring the prescribed use of medications, called medication adherence, health-care providers have to consider many risk factors such as geography (culture), social economic status, age, and low literacy that may predispose patients to non-adherence, and considerations have to be made for chronic patients living with life-long disease states. The aim of this review is to provide a balanced and comprehensive review outlining a number of different medication counselling and education approaches that have been used to try to improve medication adherence and health outcomes with the use of clear and concise graphic illustrations—called pictograms. By highlighting the current landscape of the general use and efficacy of pharmaceutical pictograms to aid in the knowledge and recall of drug-related information, as well as outlining specific medication adherence outcomes with pharmaceutical pictograms in chronic patients, the current review describes the need for health-care providers to move beyond the traditional didactic methods of oral and verbal communication with patients regarding medication-taking behavior.

Health literacy for children and families

The relationship between reading ability and health, known as health literacy, broadly reflects the skills and competencies required to operate within the healthcare environment. It is only recently that we have seen attempts to conceptualize health literacy in the context of medication use by using terms such as medication literacy. Health literacy changes over one's lifetime and is dependent on factors such as numeracy, education, income, gender and country. Low health literacy and low medication literacy have been identified as significant risk factors for poor health outcomes of adults and children. With an evaluation of common tools used to assess health literacy and medication literacy, the aim of this review is to describe the shared responsibility between patients and healthcare providers for the communication of health and medication information. Key strategies and interventions to improve two-way communication between patients and healthcare providers are highlighted, with a focus on how health literacy can impact child health outcomes.

The impact of textual elements on the comprehensibility of drug label instructions (DLIs): A systematic review

INTRODUCTION

Correct interpretation of drug labels instructions (DLIs) is needed for safe use and better adherence to prescribed drugs. DLIs are often too difficult for patients, especially for those with limited health literacy. What is yet unknown, is how specific textual elements in DLIs (e.g., the presentation of numbers, or use of medical jargon) and patients' health literacy skills are related to the comprehension of DLIs. In order to provide concrete directions for health professionals on how to optimize drug prescriptions, we performed a systematic review to summarize the available research findings on which textual elements facilitate or hinder the correct interpretation of DLIs in relation to patients' health literacy.

METHOD

A systematic search was performed in PubMed, EMBASE, PsychINFO, and Smartcat (until April 2019) to identify studies investigating textual elements that facilitate or hinder the correct interpretation of DLIs in relation to patients' health literacy.

RESULTS

A total of 434 studies were identified of which 28 studies met our inclusion criteria. We found that textual elements contributing to the correct interpretation of DLIs were: using explicit time periods in dosage instructions, using plain language, presenting numbers in a numerical format, and providing DLIs in patients' native language. Multistep instructions per instruction line, using abbreviations and medical jargon seem to hinder the correct interpretation of DLIs. Although health literacy was taken into account in a majority of the studies, none of them assessed the effectiveness of specific textual elements on patients' comprehensibility of DLIs.

CONCLUSION

Based on our findings, we provide an overview of textual elements that contribute to the correct interpretation of DLIs. Optimizing the textual instruction on drug labels may increase the safety and adherence to prescribed drugs, taking into account that a significant proportion of patients has low health literacy.

Experiences and perceptions of foreign-language customers on medication information received in the pharmacy - a focus group study

BACKGROUND

In pharmacies, communication is essential for providing information about medicine and counselling customers on the correct use of medications. Previous studies have described pharmacists experiencing language and cultural barriers in communication with foreign-language (FL) customers.

OBJECTIVE

This study aimed to explore FL customer experiences and perceptions of medication information received in the pharmacy.

METHODS

A qualitative method was used, including interviews in five focus groups. Study participants (N = 18) spoke Arabic or Kurdish but lived in Norway and had the experience of purchasing medicine over the counter and/or prescription medicines in a Norwegian pharmacy. A descriptive thematic content analysis was conducted.

KEY FINDINGS

Overall, the FL customers were satisfied with the pharmacy service. However, they were divided in their views of the pharmacy role, which could affect how they received medication information. Communication barriers were prominent, and FL customers related language and cultural barriers to negative health outcomes. Their preferences on medication information were not met. Several communication facilitators that could support medication information were mentioned: simplified prescription labels, written information, pictograms, mobile apps, interpretators and bilingual staff.

CONCLUSIONS

The FL pharmacy customers' experience of communication barriers and unfulfilled needs for medical information can be a threat to patient safety. To overcome the barriers and ensure the correct use of medicines, health-care personnel in pharmacies must apply an array of communication aids, adapted to the diversity in language, culture and health literacy in the heterogenous population.

Development and Assessment of a Pictographic Pediatric Constipation Action Plan

OBJECTIVE

To assess the Uniformed Services Constipation Action Plan (USCAP) as an evidence-based, personalized, clinical action tool with pictograms to aid clinicians and families in the management of functional constipation.

STUDY DESIGN

The USCAP facilitates the management functional constipation by using a health literacy-informed approach to provide instructions for pharmacotherapies and lifestyle modifications. This study included part 1 (pictogram validation) and part 2 (assessment). For part 1, pictogram transparency, translucency, and recall were assessed by parent survey (transparency ≥85%, mean translucency score ≥5, recall ≥85% required for validation). For part 2, the USCAP was assessed by parents, clinical librarians, and clinicians. Parental perceptions (n = 65) were assessed using the Consumer Information Rating Form (17 questions) to gauge comprehensibility, design quality and usefulness. Readability was assessed by 5 formulas and a Readability Composite Score was calculated. Clinical librarians (n = 3) used the Patient Education Materials Assessment Tool to measure understandability (19 questions) and actionability (7 questions) (>80% rating was acceptable). Suitability was assessed by clinicians (n = 34) using Doak's Suitability Assessment of Materials (superior ≥70% rating).

RESULTS

All 12 pictograms demonstrated appropriate transparency, translucency, and recall. Parental perceptions reflected appropriate comprehensibility, design quality, and usefulness. The Readability Composite Score was consistent with a fifth-grade level. Clinical librarians reported acceptable understandability and actionability. Clinicians reported superior suitability.

CONCLUSIONS

The USCAP met all criteria for clinical implementation and future study of USCAP implementation for treating children with chronic functional constipation.

Development of Comprehensible Prescription Label Instructions: A Study Protocol for a Mixed-Methods Approach

Introduction

Patients receive information about their medication from different sources, including prescription labels. These labels are physically attached to each package dispensed to patients and contain the most important instructions on how to use the medication correctly. However, many patients experience difficulties in understanding and applying the instructions on these labels correctly, especially patients with limited health literacy. The aim of this study is to investigate the comprehensibility of prescription label instructions among patients with adequate and limited health literacy skills, and to implement improvements in primary health care.

Methods

We used a mixed-methods approach, which consisted of four phases. Phase 1 (desk research) was divided into a systematic literature review on the comprehensibility of prescription label instructions (1a) and a content analysis of the textual elements in Dutch prescription label instructions (1b). In phase 2 (patient studies), semi-structured interviews were conducted to investigate the comprehensibility of seven prescription labels among patients with different health literacy skills (2a), and a quantitative study in which the comprehensibility of six optimized prescription labels was compared among patients with different health literacy skills (2b). Patient studies were conducted in eight Dutch pharmacies. In phase 3 optimized prescription label instructions were implemented in national medication databases which has been supported by a guideline (3a), and education of pharmacy workers (3b). Phase 4 consists of evaluating the optimized prescription label instructions by experiences from patients and pharmacists.

Anticipated Results

This mixed-methods approach will result in scientific publications of the individual studies, and a guideline on how to compose comprehensible prescription label instructions to be put on medication packages. Optimized prescription label instructions will be implemented in national medication databases.

Discussion

This protocol describes a mixed-method research to compose and implement comprehensible prescription label instructions and will lead to knowledge about the comprehensibility of textual elements in these labels, with specific attention for patients with limited health literacy. Implementation of optimized prescription label instructions will lead to a better understanding of them, which may contribute to improved medication adherence. A limitation is that non-textual aspects of prescription labels are not investigated.