Communication in the clinical setting

Patient compliance: the pharmacist's role

Pharmacists can influence patients' compliance with prescribed medicines not only by educating and informing patients but also by helping to simplify their medication regimens. This article discusses the measurement of compliance and looks at ways of improving it.

Developing and testing a patient information booklet for thrombolysis used in acute stroke

Objective  Thrombolysis decreases the chance of post-stroke dependence, although its use carries significant risk, notably of intra-cerebral haemorrhage. Patients (and families) face an important risk/benefit decision before consenting. We drafted a patient information booklet for this purpose, and applied performance-based readability testing with the aim that the most important information in the booklet could be found and understood. Methods  The booklet was developed with reference to best practice in information writing and design. We User-Tested its performance on 56 people without prior experience of stroke. After reading the booklet they were asked to find and explain 15 pieces of information. The booklet was revised according to its performance and re-tested, until each item was found and understood by at least 80% of participants. Key findings  The four-page information booklet contained approximately 900 words, organised into six sections. A risk-palette graphic showed the chance of positive and negative outcomes. The booklet was tested on four participant cohorts and revised, including more bold text, re-wording, changing the title and changing the graphic to a coloured bar chart. Testing the final version on the fourth cohort of 20 people showed that each of the 15 tested items of information met the target of at least 80% participants being able to find and understand it. Conclusions  The use of information design and User Testing produced a booklet that is understandable by people with no prior experience of stroke. User Testing is an inexpensive and quick method to ensure that information intended for patients is usable.

Performance-based readability testing of participant information for a Phase 3 IVF trial

BACKGROUND

Studies suggest that the process of patient consent to clinical trials is sub-optimal. Participant information sheets are important but can be technical and lengthy documents. Performance-based readability testing is an established means of assessing patient information, and this study aimed to test its application to participant information for a Phase 3 trial.

METHODS

An independent groups design was used to study the User Testing performance of the participant information sheet from the Phase 3 'Poor Responders' trial of In Vitro Fertilisation (IVF). 20 members of the public were asked to read it, then find and demonstrate understanding of 21 key aspects of the trial. The participant information sheet was then re-written and re-designed, and tested on 20 members of the public, using the same 21 item questionnaire.

RESULTS

The original participant information sheet performed well in some places. Participants could not find some answers and some of the found information was not understood. In total there were 30 instances of information being not found or not understood. Answers to three questions were found but not understood by many of the participants, these related to aspects of the drug timing, Follicle Stimulating Hormone and compensation. Only two of the 20 participants could find and show understanding of all question items when using the original sheet. The revised sheet performed generally better, with 17 instances of information being not found or not understood, although the number of 'not found' items increased. Half of the 20 participants could find and show understanding of all question items when using the revised sheet. When asked to compare the versions of the sheet, almost all participants preferred the revised version.

CONCLUSION

The original participant information sheet may not have enabled patients fully to give valid consent. Participants seeing the revised sheet were better able to understand the trial. Those who write information for trial participants should take account of good practice in information design. Performance-based User Testing may be a useful method to indicate strengths and weaknesses in trial information.

Design, development, and evaluation of visual aids for communicating prescription drug instructions to nonliterate patients in rural Cameroon

In this study, culturally sensitive visual aids designed to help convey drug information to nonliterate female adults who had a prescription for a solid oral dosage form of antibiotic medications were developed and evaluated. The researchers conceptualized the educational messages while a local artist produced the visual aids. Seventy-eight female ambulatory patients were evaluated for comprehension and compliance with antibiotic prescription instructions. The study was conducted in three health centers in Cameroon, West Africa and followed a pre-test, post-test, and follow-up format for three groups: two experimental, and one control. All participants were randomly assigned to either experimental or control groups, 26 patients to each group. Subjects in the experimental groups received visual aids alone or visual aids plus an Advanced Organizer. A comparison of the three groups showed that subjects in the experimental groups scored significantly higher than the control group in both the comprehension and compliance measures.

Effects of information-giving and communication during orthodontic consultation and treatment. Part 3: Optimized orthodontist-patient communication

Effective, orthodontist-patient communication must meet certain minimum requirements whose importance might vary, depending on the individual case and stage of treatment. In the course of treatment the following tasks are of primary importance: 1. Before the start of treatment, during preliminary consultation, information tailored in extent and quality to the individual patient has to be provided, a professional assessment of treatment needs made, and a relationship of mutual trust established. 2. In the initial phase of treatment, the individual shaping and optimisation of treatment needs is a matter of priority if initial acceptance of the appliance is to be assured. The patient should be advised how to meet the treatment needs in his individual situation. 3. In the further course of treatment, the fulfillment of the demands has to be repeatedly clarified. Feedback with regard to patient cooperation should be handled with caution. A tight recall schedule, a time-keeping record and involvement of the parents are obvious interventions in cases of inadequate cooperation. The treatment may also have to be reevaluated.

[The effect of information and communication in the orthodontic consultation. 1. The imparting of the information]

The initial consultation has a crucial impact on the patient's decision whether or not to undergo orthodontic treatment. The consultation is the occasion for providing information regarding the nature of the malocclusion and its possible treatment. The consultation has a threefold objective: first, the ethical, i.e. assisting the patient in making an informed and responsible decision; second, the legal, i.e. facilitation of an informed consent; and third, the psychological, i.e. motivation to treatment and enhanced health behavior. The basic prerequisites to a successful consultation are the patient's accurate comprehension and retention of the given information. In the course of an ongoing quasi-experimental study the Wuerzburg orthodontic department has made video recordings of initial consultations. All information was coded according to a standardized schematic. After ten days the patients were interviewed about the consultation. With help of the schematic, retention and comprehension of the information given were assessed quantitatively by comparing the number of information units actually given with those recalled, understood, or forgotten. In addition, the recordings were analyzed for provider interaction patterns.

Sex and the nation's health

The Government's 'Health of the Nation', influenced by the WHO's 'Global Strategy for Health for All by the Year 2000', pledges a reduction in sexually transmitted diseases in general and AIDS in particular. The recommendations are clearly sensible but how do you persuade people to believe and comply with the 'sensible' advice? Failure to consider public health measures involving sexual behaviour without considering how different cultures respond and interpret the advice given is bound to fail. People are individuals and there is a danger in assuming that our values and beliefs are shared by people globally. For a message to succeed it needs to be simple and direct, and portrayed in its cultural context through an appropriate medium. An appreciation that the message however sensible may clash with individual needs (eg the economics of prostitution) and research into these aspects of sexual behaviour will ensure that the message remains effective. Changing the slogans and methods of conveying the message regularly will help to reinforce key points and reduce apathy.

Increased readability improves the comprehension of written information for patients with skin disease

Many standardized methods are available with which to evaluate the reading ease and comprehensibility of written material. Techniques depend on mechanical analysis of sentence length, multiple prepositional phrases, direct phraseology, and arrangement of printed materials on the page. Those techniques were used to analyze a pamphlet designed for patient education by the American Academy of Dermatology. The pamphlet scored a reading ease grade of 45, corresponding to what is considered difficult reading and at a level commonly found in academic journals. We rewrote the pamphlet and increased its reading ease score to 62.4, corresponding to material that appears in standard digest-type magazines. We gave both versions of the pamphlet to a group of first-year medical students and to a group of middle-class patients from a dermatology practice. In both groups the modified version led to greater understanding of the written material. We conclude that the usefulness of patient education materials now being distributed by dermatologists could be significantly improved by being rewritten according to well-recognized formulas.

Strategies to improve compliance with therapy

The failure of patients to comply with their therapeutic regimen has an extensive impact on the costs and strategies of medical care. Compliance with long-term regimens can be improved by linking the timing of the medication to existing daily habits, reducing the number of times that a medication is to be taken each day, and identifying the side effects that a patient attributes to the treatment. In addition, providing written instructions, shortening the duration of therapy, and periodically evaluating compliance by determining drug serum levels can reduce non-compliant behavior. The establishment of a strong patient/physician relationship is central to long-term therapeutic success.

A method for decreasing patients' medication errors

Eighty anxious and eighty depressed patients were assigned randomly to receiving one of three versions of an information leaflet about their medication, or to receiving no leaflet at all. Mean medication errors were reduced from 15 to 4% by provision of suitably constructed leaflets. The results show the practical importance of informing patients about their medication and of paying attention to the difficulty level of any leaflets issued.