Providing patients with written medication information

Information About the Optimism of a Placebo/Nocebo Provider and Placebo/Nocebo Side Effects

Background

Research has demonstrated that personality characteristics, such as optimism are associated with placebo/nocebo responding. The present study investigated whether written information about the optimism of a placebo/nocebo provider can influence the occurrence of reported placebo/nocebo side effects.

Method

We analyzed data from 201 females (mean age = 26 years) who participated in a “clinical study on a new massage oil with stone clover extract.” The oil (sunflower oil) was introduced as either eliciting a negative side effect (unpleasant itching; “nocebo oil”) or a positive side effect (pleasant tingling; “placebo oil”). The administration of the oil was combined with written information about the maker of the product. The oil maker was either portrayed as a very optimistic person or no personal information was provided (only the company name). The participants had no personal contact with the experimenter and received all materials and instructions per post.

Results

The participants reported more frequent and intense itching when they received a nocebo suggestion compared to a placebo suggestion. Positive tingling sensations were reported more frequently than itching but did not differ between the placebo/nocebo conditions. Information about the optimism of the oil maker was associated with a lower frequency of reported side effects (adverse and beneficial).

Conclusion

This study demonstrated that it is sufficient to provide participants with written information about an inert substance to elicit the suggested side effect. Information about the provider’s optimistic personality did not specifically influence reported side effects. Future studies should focus on how to adapt written information about a drug/product to minimize adverse side effects and to maximize positive side effects.

Legislation for patient information leaflets in Iran: Focus on lay-friendliness

Background: Patient information leaflet (PIL) which accompanies medicinal products and informs patients about dosage, side effects, etc., is known as a tool which empowers patients to be more involved in making decisions related to their medications and health. In recent years, policy makers have paid much attention to PIL and its lay-friendliness i.e. being clear,explicit, and easy to read and understand. In various countries, PIL is known as a legal genre and must be prepared in understandable language. The present study aimed to situate PIL within its institutional context and investigate the importance is given to the lay-friendliness of PIL in Iran.

Methods: In this observational study, official website of Food and Drug Administration of the Islamic Republic of Iran (IFDA) was consulted. Iran’s rules and regulations, legal requirements,linked to PIL production and translation were introduced and discussed in relation to lay-friendliness..

Results: Limited legislation relevant for the production and translation of lay-friendly PIL was found. The IFDA has not issued any documents or guidelines which exclusively concern lay- friendliness of PIL. Any methods which can assess lay-friendliness in original and translated PILs were not observed.

Conclusion: The IFDA, the authoritative body in charge of legislation concerning PIL, has given limited importance to the language used in PIL and its lay-friendliness, witnessed by the limited legislation which is relevant for the production and translation of easy-to-understand PIL. It is not clear that how the IFDA assesses quality and lay-friendliness of original and translated PILs.

Engaging women with an embodied conversational agent to deliver mindfulness and lifestyle recommendations: A feasibility randomized control trial

OBJECTIVE

This randomized controlled trial evaluates the feasibility of using an Embodied Conversational Agent (ECA) to teach lifestyle modifications to urban women.

METHODS

Women were randomized to either 1) an ECA (content included: mindfulness, stress management, physical activity, and healthy eating) or 2) patient education sheets mirroring same content plus a meditation CD/MP3 once a day for one month. General outcome measures included: number of stress management techniques used, physical activity levels, and eating patterns.

RESULTS

Sixty-one women ages 18 to 50 were enrolled. On average, 51% identified as white, 26% as black, 23% as other races; and 20% as Hispanic. The major stress management techniques reported at baseline were: exercise (69%), listening to music (70%), and social support (66%). After one month, women randomized to the ECA significantly decreased alcohol consumption to reduce stress (p=0.03) and increased daily fruit consumption by an average of 2 servings compared to the control (p=0.04).

CONCLUSION

It is feasible to use an ECA to promote health behaviors on stress management and healthy eating among diverse urban women.

PRACTICE IMPLICATIONS

Compared to patient information sheets, ECAs provide promise as a way to teach healthy lifestyle behaviors to diverse urban women.

The Journey to Become a Health Literate Organization: A Snapshot of Health System Improvement

A health literate health care organization is one that makes it easy for people to navigate, understand, and use information and services to take care of their health. This chapter explores the journey that a growing number of organizations are taking to become health literate. Health literacy improvement has increasingly been viewed as a systems issue, one that moves beyond siloed efforts by recognizing that action is required on multiple levels. To help operationalize the shift to a systems perspective, members of the U.S. National Academies of Sciences, Engineering, Medicine Roundtable on Health Literacy defined ten attributes of health literate health care organizations. External factors, such as payment reform in the U.S., have buoyed health literacy as an organizational priority. Health care organizations often begin their journey to become health literate by conducting health literacy organizational assessments, focusing on written and spoken communication, and addressing difficulties in navigating facilities and complex systems. As organizations' efforts mature, health literacy quality improvement efforts give way to transformational activities. These include: the highest levels of the organization embracing health literacy, making strategic plans for initiating and spreading health literate practices, establishing a health literacy workforce and supporting structures, raising health literacy awareness and training staff system-wide, expanding patient and family input, establishing policies, leveraging information technology, monitoring policy compliance, addressing population health, and shifting the culture of the organization. The penultimate section of this chapter highlights the experiences of three organizations that have explicitly set a goal to become health literate: Carolinas Healthcare System (CHS), Intermountain Healthcare, and Northwell Health. These organizations are pioneers that approached health literacy in a systematic fashion, each exemplifying different routes an organization can take to become health literate. CHS provides an example of how, even when the most senior leadership drives the organization to become health literate, continued progress requires constant reinvigoration. At Intermountain Healthcare, the push to become a health literate organization was the natural consequence of organizational adoption of a model of shared accountability that necessitated patient engagement for its success. Northwell Health, on the other hand, provides a model of how a persistent champion can elevate health literacy to become a system priority and how system-wide policies and procedures can advance effective communication across language differences, health literacy, and cultures. The profiles of the three systems make clear that the opportunities for health literacy improvement are vast. Success depends on the presence of a perfect storm of conditions conducive to transformational change. This chapter ends with lessons learned from the experiences of health literacy pioneers that may be useful to organizations embarking on the journey. The journey is long, and there are bumps along the road. Nonetheless, discernable progress has been made. While committed to transformation, organizations seeking to be health literate recognize that it is not a destination you can ever reach. A health literate organization is constantly striving, always knowing that further improvement can be made.

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.

Guidance on how to achieve comprehensible patient information leaflets in four steps

Comprehensible information leaflets can improve a patient's knowledge. However, in clinical studies leaflets are often introduced without meticulously verifying their comprehensibility. In an attempt to provide a feasible guidance on how to design comprehensible leaflets we complied and evaluated an easy-to-use development procedure. In January 2015, a literature search was performed to identify evidence for readily available quality assurance strategies as a starting point for a standardized strategy to develop and validate written patient information. The suggested development strategy is a consecutive four-step procedure that comprised already validated distinct quality assessments: (i) an initial requirement analysis specifying the needs and constraints of the target population and evidence-based preparation of the leaflets, (ii) a readability assessment, (iii) the Suitability Assessment of Materials instrument and (iv) iterative consumer test in the target population. The consecutive combination of pertinent and previously validated quality assessments provides an easy-to-use guidance on how to create comprehensibly written patient information, particularly for small-scale research projects with time and money constraints.

Tools used to evaluate written medicine and health information: document and user perspectives

This study aims to identify and review tools used to evaluate consumer-oriented written medicine (WMI) and health (WHI) information from a document and user perspective. Articles that met the following inclusion criteria were reviewed: studies evaluating readability, presentation, suitability, quality of WMI/WHI. A total of 152 articles were identified, of which 64 satisfied the inclusion criteria. Fifty-nine original studies used evaluation tools and 5 reviewed a specific group of tools. Sixteen detailed the development or validation of an instrument. Fifteen studies evaluated WMI and 28 evaluated WHI. Twenty-three evaluation instruments were identified. Of the seven readability tests, SMOG was predominantly used (12 of 43 studies). Eight tools measured health literacy, with REALM being the most popular instrument (7 of 43). SAM was the most commonly used presentation tool (12 of 43 studies). Many tools are available to evaluate WMI and WHI. However, the majority are researcher focused. Most evaluate readability and presentation, revealing a gap in valid and reliable tools for assessing quality of information, and those that can be used by consumers.

Patient receipt of, and preferences for receiving, antidepressant information

Objective

The purpose of the study was to examine patient receipt of, and preferences for receiving, antidepressant information.

Method/setting

The study had a cross-sectional design. Eight community pharmacies in central North Carolina participated in the study. Eighty-three English-speaking patients who were picking up antidepressant prescriptions were interviewed by a research assistant. The main outcome measures included: patient receipt of verbal antidepressant information; the number and type of educational messages contained in the written antidepressant leaflets that patients received; the percentage of patients who had a reading level below the reading level of the antidepressant information leaflet; whether patients reported reading the leaflets and how satisfied they were with the leaflets; and how patients preferred to receive antidepressant information.

Key findings

Seventeen per cent of patients did not receive verbal information about how long the medication would take to work from anyone. Only 50 per cent of patients were told what to do if a major side effect occurred. Almost 11 per cent of patients had a reading level below the level of the written pharmacy antidepressant information leaflet. Just over one-third (36 per cent) of patients preferred to receive only written antidepressant information. Less educated patients were significantly more likely to want to receive antidepressant information verbally. Of those patients who preferred to receive verbal antidepressant information or both verbal and written information, 92 per cent chose pharmacists as their first or second choice for providing them with verbal information.

Conclusion

The majority of patients taking antidepressants want to receive verbal information and view pharmacists as an important source of information. Pharmacists have the potential to improve antidepressant adherence if they take the time to educate patients verbally about their medications.

Providing health information to older adults

Providing information to older adults is essential for informed decision-making and good health. Because there are significant deficits in providing information verbally, health professionals must use written information as well. Most studies have focused on the content and literacy of documents. However, the legibility and formatting are critically important for older adults, who are more likely to suffer with visual impairment. Providing written information that is tested for appropriate reading level and for presentation is necessary to ensure that older adults can use the information given. There are a number of tools available that test these aspects of written information, but not one tool that is universally accepted. Further research regarding the design and presentation of written information for older adults is necessary.

Typeface legibility of patient information leaflets intended for community-dwelling seniors

BACKGROUND

there are guidelines available from a number of countries and organisations regarding the design of written information, as appropriate design is essential for effective communication. The design of leaflets should be evaluated, as written information that does not adhere to guidelines may not be effective for seniors.

OBJECTIVE

to use current typeface guidelines to describe the design of health information leaflets.

DESIGN

this was a cross-sectional study of leaflets from pharmacies and seniors' clinics.

SETTING

community pharmacies, seniors' clinics in Edmonton, Canada.

METHODS

health information leaflets and hydrochlorthiazide information sheets were collected. The body of each was evaluated, based on guidelines (from Canada, UK and USA). Adherence to recommendations was assessed descriptively.

RESULTS

a total of 388 unique leaflets and 10 hydrochlorthiazide sheets were collected from 21 pharmacies and 3 clinics. Most leaflets were produced by pharmaceutical companies (42.8%) and contained disease information (43.8%). Only one-third of all leaflets used the minimum recommended point size (12 point), 18.6% followed American guidelines for line spacing (1.5 lines), but 77.1% had appropriate contrast.

CONCLUSIONS

although guidelines are available, most leaflets did not meet recommendations. Improvements in the leaflet design should be considered to aid seniors in the uptake of information.

Written information about individual medicines for consumers

BACKGROUND

Medicines are the most common intervention in most health services. As with all treatments, those taking medicines need sufficient information: to enable them to take and use the medicines effectively, to understand the potential harms and benefits, and to allow them to make an informed decision about taking them. Written medicines information, such as a leaflet or provided via the Internet, is an intervention that may meet these purposes.

OBJECTIVES

To assess the effects of providing written information about individual medicines on relevant patient outcomes (knowledge, attitudes, behaviours and health outcomes) in relation to prescribed and over-the-counter medicines.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, CINAHL, The Cochrane Library, PsycINFO and other databases to March 2007. We handsearched five journals' tables of contents, and the reference lists of included studies, and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of medicine users, comparing written medicines information with no written medicines information; or trials that compared two or more styles of written medicines information. We only included trials that measured a knowledge, attitudinal or behavioural outcome. There were no language restrictions.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data relating to the interventions, methods of the trials, and outcome measures; and reconciled differences by discussion. Heterogeneity of interventions and outcomes measured meant that data synthesis was not possible. The results are presented in narrative and tabular format.

MAIN RESULTS

We included 25 RCTs involving 4788 participants. Six of twelve trials showed that written information significantly improved knowledge about a medicine, compared with no written information. The inability to combine results means we cannot conclude whether written information was effective for increasing knowledge. The results for attitudinal and behavioural outcomes were mixed. No studies showed an adverse effect of medicines information.

AUTHORS' CONCLUSIONS

The combined evidence was not strong enough to say whether written medicines information is effective in changing knowledge, attitudes and behaviours related to medicine taking. There is some evidence that written information can improve knowledge. The trials were generally of poor quality, which reduces confidence in the results. Trials examining the effects of written information need to be better designed and use consistent and validated outcome measures. Trials should evaluate internet-based medicines information. It is imperative that written medicines information be based on best practice for its information design and content, which could improve its effectiveness in helping people to use medicines appropriately.

Key Principles to Guide Development of Consumer Medicine Information—Content Analysis of Information Design Texts

Background:

Effective written consumer medicines information is essential to support safe and effective medicine taking, but the wording and layout of currently provided materials do not meet patients' needs.

Objective:

To identify principles from the wider discipline of information design for use by health professionals when developing or assessing written drug information for patients.

Methods:

Six experts in information design nominated texts on best practice in information design applicable to consumer medicines information. A content analysis identified key principles that were tabulated to bring out key themes.

Results:

Six texts that met the Inclusion criteria, were Identified, and content analysis indentified 4 themes: words, type, lines, and layout. Within these main themes, there were 24 subthemes. Selected principles relating to these subthemes were: use short familiar words, short sentences, and short headings that stand out from the text; use a conversational tone of voice, addressing the reader as “you”; use a large type size while retaining sufficient white space; use bullet points to organize lists; use unjustified text (ragged right) and bold, lower-case text for emphasis. Pictures or graphics do not necessarily improve a document.

Conclusions:

Applying the good information design principles identified to written consumer medicines information could support health professionals when developing and assessing drug information for patients.

Impact of bilingual product information labels on Spanish-speaking adults' ability to comprehend OTC information

BACKGROUND

There is a steady growth in the Spanish-speaking population in the United States. Language may be a barrier in accessing nonprescription medication information for the non-English-speaking population.

OBJECTIVE

The objective of this study was to compare consumer-reported ease of use, product knowledge, and intention to purchase over-the-counter (OTC) medications using bilingual Product Information Labels (PILs) and currently available label formats in a sample of Spanish-speaking consumers.

METHODS

Participants were randomly selected from Spanish-speaking consumers shopping for OTC medications in pharmacy or grocery stores in Houston, TX. Participants viewed 3 label formats (old, new, and PILs) for acetaminophen, ibuprofen, and aspirin in a random order. Questionnaires in English and in Spanish were provided to consumers after they viewed each label format. Domains measured in the questionnaires included ease of use, product knowledge, and purchase intention. All responses were measured on a 7-point Likert-type scale. Data were recoded and analyzed using SAS (version 9.0) (SAS Institute Inc, Cary, NC) to obtain mean scores for each domain. Participants were classified according to language proficiency into "Spanish only" and bilinguals. Comparative statistics were computed to compare mean scores between label formats in each consumer category.

RESULTS

A total of 225 questionnaires were collected. The mean (+/-standard deviation) age of participants was 38.91 (+/-11.95) years. A majority of respondents were Hispanic (97.75%), female (60.54%), and married (62.44%). Mean scores from viewing PILs on ease of use, product knowledge, and purchase intention were higher than those from viewing the other label formats. In the category of consumers who spoke Spanish only, mean scores of PILs were significantly higher as compared to those of old and new label formats (P<.05).

CONCLUSION

Information provided in Spanish on PILs may be very helpful to the Spanish-speaking community when selecting nonprescription medications. Policy makers and health care providers should consider PILs as an effective means of reducing language barriers and providing OTC medication information to the Spanish-speaking population in the United States.

The role and value of written information for patients about individual medicines: a systematic review

OBJECTIVE

To review research on the role and value of written medicines information for patients from the perspective of patients and health professionals.

CONTEXT

Providing written information to patients about their medicines is acknowledged as a priority but there is poor understanding of how best to meet patients' needs.

METHOD

A sensitive search strategy was developed to maximize the identification of relevant studies. We used a data extraction form designed to appraise qualitative research. Findings were synthesized into a narrative account.

MAIN RESULTS

There were three broad categories of study: those which related to policy initiatives; those where the aim was to increase compliance; and those concerned with using information to support decision-making ('informed patient' studies). While the policy initiative and compliance studies reported that, mostly, patients were positive about written information, the 'informed patient' studies showed a more complex picture. Patients valued medicines information tailored to their condition. They did not want it to be a substitute for spoken information from their doctor. Not everyone wanted written information but those who did wanted sufficient detail to meet their need. Need varied over time and between patients. The small number of studies relating to health professionals showed widespread ambivalence towards using written information. Some thought it should be brief and simple, only partially disclose side-effects and saw its main role as being to increase compliance.

CONCLUSION

The different perspectives of patients and health professionals, and the diverse and changing information needs of patients pose a challenge to providers of written medicines information.

Language barriers to prescriptions for patients with limited English proficiency: a survey of pharmacies

BACKGROUND

Twenty-three million Americans have limited English proficiency. Language barriers can have major adverse consequences in health care, but little is known about whether pharmacies provide adequate care to patients with limited English proficiency.

OBJECTIVES

We sought to evaluate pharmacies' ability to provide non-English-language prescription labels, information packets, and verbal communication, and assess pharmacies' satisfaction with communication with patients who have limited English proficiency.

METHODS

We used a cross-sectional, mixed-methods survey of Milwaukee County, Wisconsin, pharmacies. Survey questions addressed sociodemographic and language-service characteristics of pharmacies. A pharmacist or technician at each pharmacy was asked 45 questions by telephone, fax, or mail. The main outcome measures were the ability of pharmacies to provide non-English-language prescription labels, information packets, and verbal communication; and pharmacy satisfaction with communication with patients who have limited English proficiency.

RESULTS

Of 175 pharmacies, 73% responded. Forty-seven percent of the pharmacies never/only sometimes can print non-English-language prescription labels, 54% never/only sometimes can prepare non-English-language information packets, and 64% never/only sometimes can verbally communicate in non-English languages. Eleven percent use patients' family members/friends to interpret. Only 55% were satisfied with their communication with patients who have limited English proficiency. In multivariate analyses, community pharmacies had significantly lower odds of being able to verbally communicate in non-English languages, whereas pharmacies using telephone interpreting services had significantly higher odds. Pharmacies' suggestions for improving patient communication included continuing education, producing a chain-wide list of resources, hiring bilingual staff, using telephone interpreters, analyzing translation quality/accuracy of labels and information packets, and adding more languages to pharmacy software.

CONCLUSIONS

Approximately half of Milwaukee pharmacies never/only sometimes can provide non-English-language prescription labels or information packets, and approximately two thirds never/only sometimes can verbally communicate in non-English languages. One in 9 pharmacies that verbally communicate in non-English languages use patients' family members/friends to interpret. Almost half of the pharmacies are dissatisfied with their communication with patients who have limited English proficiency. Community pharmacies are less likely and pharmacies using telephone interpreting services are more likely to be able to verbally communicate in non-English languages. Study findings indicate that improvements in pharmacies' communication with patients who have limited English proficiency may result by increasing the quality and number of non-English languages in existing computer programs, hiring bilingual staff, and using telephone interpreting services when in-person interpreters are unavailable.

Patient receipt and understanding of written information provided with isotretinoin and estrogen prescriptions

BACKGROUND

Medication guides (MG) and mandatory patient package inserts (MPPI) are required with some prescription medications.

OBJECTIVE

We sought to determine how many patients receive, read, and understand these mandated materials.

DESIGN AND PARTICIPANTS

A total of 3,620 patients were identified as filling prescriptions for isotretinoin or selected estrogen products from February 2004 to January 2005. Patients were surveyed to gauge receipt and understanding of the MG for isotretinoin and the MPPI for estrogen.

MEASUREMENTS AND MAIN RESULTS

A total of 500 patients completed the survey, with 186 (93%) of the 200 isotretinoin patients and 258 (86%) of the 300 estrogen patients reporting receipt of the MG/MPPI with their most recent prescription. The majority of respondents reported confidence in their knowledge of their medication (86% for isotretinoin and 75% for estrogen). However, the mean score on 5 questions assessing recognition of medication risks was only slightly better than the score expected from guessing (3.1 vs 2.5, P < .01 for both isotretinoin and estrogen).

CONCLUSIONS

Despite receiving the information and reporting confidence in medication knowledge, patients' understanding of major risks with these medications was poor. This finding highlights the need to develop better risk communication strategies to improve the safe and effective use of prescription medications.

Do themes in consumer medicines information literature reviews reflect those important to stakeholders?

OBJECTIVE

To compare the themes emerging from a stakeholder workshop on consumers' medicines information with themes in relevant published reviews.

METHODS

A stakeholder workshop was held to permit consumer orientation of a systematic review of consumer medicines information. Analysis of the workshop outputs was compared to a content analysis of the identified published reviews.

RESULTS

The workshop generated a range of responses inductively grouped into 12 over-arching themes. No reviews tackled all of these themes, nor addressed 'informed choice and autonomy'. More recent reviews reflected more workshop themes than older ones, suggesting a temporal trend towards a greater sensitivity to consumer issues. The most common workshop themes were covered by all reviews. Six themes in the reviews were related to traditional professional concerns including compliance, which did not arise in the workshop.

CONCLUSION

The results highlight a mismatch between the themes in previous published reviews and the themes emerging from the workshop. The most commonly reflected themes in reviews conform to the 'patient education' model of discourse, while workshop themes less often echoed in reviews reflect the discourse of 'patient empowerment'.

PRACTICE IMPLICATIONS

The findings suggest the importance of involving patients in the development of patient literature from the outset.

Development of written information for antiretroviral therapy: comprehension in a Tanzanian population

OBJECTIVE

To design and develop a simple, easily readable patient information leaflet (PIL) for a commonly used antiretroviral (ARV) regimen and to evaluate its readability and acceptability in a Tanzanian population.

METHOD

A PIL incorporating simple text and pictograms was designed for the antiretroviral regimen of stavudine, lamivudine and efavirenz. The PIL was designed according to established good design guidelines, modified during a multi-stage iterative testing process and piloted in a South African Xhosa population. The PIL was made available in both English and Kiswahili. Sixty Tanzanian participants who were not taking ARVs were interviewed. They were asked to read the PIL in the language of their choice and were then asked a series of two-part questions; the first part required participants to locate the information in the PIL, after which they were asked to explain the information in their own words. Acceptability was assessed through close-ended questions and open-ended feedback. The influence of selected patient characteristics on comprehension of the PIL was investigated using one-way ANOVA and t-tests for independent samples with a significance level set at 0.05.

MAIN OUTCOME MEASURE

Comprehension of the written information in an overall percentage understanding.

RESULTS

The overall average percentage comprehension of the PIL was 95%. The target set by the EC guideline that at least 80% of participants correctly locate and understand the information was achieved for 19 of the 20 questions. Five of the six instructions illustrated by pictograms were correctly understood by all participants. The only patient characteristics significantly associated with comprehension were educational level and self-reported ease of reading the PIL. Acceptability of the PIL was high and positive comments were associated with simplicity, good design, easy readability and user-friendliness, the latter enhanced by the inclusion of pictograms.

CONCLUSION

The PIL designed for this study was shown to be effective in communicating information about ARVs. Patient characteristics must be taken into account when developing written information, and the final document must be tested for comprehension in the target population.

Initial evaluation of a computer-based medication management tool in a geriatric clinic

BACKGROUND

Optimal management of medication regimens remains a challenge for elderly patients and their providers. Tools that aid communication and adherence can be valuable but often do not meet expectations.

OBJECTIVE

The purpose of this article was to describe the development and preliminary evaluation of a computer-based medication management tool, the Visual Medication Profile (VMP), and to report initial feedback from geriatric patient and provider focus groups.

METHODS

For VMP development, an interdisciplinary team (ie, physicians, nurses, pharmacists, computer analysts, and programmers) designed the fully automated, Web-based intervention that integrates the Veterans Affairs Medical Center (VAMC) computer pharmacy system with the computerized patient record system. In addition to development of the required technology, a mixed methods design and a convenience sample were used to collect pilot data related to patient-provider issues about medication management, and the acceptance, feasibility, and usefulness of the VMP. This involved the use of focus groups and a pilot study group.

RESULTS

First, the interdisciplinary team developed the VMP by integrating data from the pharmacy database, the patient's database, and a pill photograph database. Second, patients and providers in the focus groups discussed medication management issues and evaluated a sample VMP. Patients (n = 8; mean age, 76 years; 5 black, 3 white) noted the following medication management problems: (1) not understanding the information provided by the physician; (2) multiple providers; and (3) unpronounceable names of medications. Providers (n = 8 [4 physicians, 4 nurse practitioners]) noted that patients and providers use different language to discuss medications; that there is a lack of congruence between patients' self-report of current medications and their medical record; and that there are severe time constraints for clinic appointments and concern regarding introducing a new clinical tool. Both groups favored a VMP-like tool to improve communication. In the VMP prototype pilot study, a patient-specific VMP was developed for each of 6 subjects (mean age, 79.7 years; 3 black, 3 white) from the outpatient geriatric clinic. Congruence rates ranged from 51% to 100%. Five of the 6 subjects participated in follow-up. The nurse's telephone log from the pilot study revealed that although 4 out of the 5 subjects and/or caregivers reported that they favored the VMP as a medical management tool, the use of the VMP at home varied considerably.

CONCLUSIONS

The VMP is a promising tool for use by both patients and providers to improve medication management. Although it was developed in the VAMC system, its Web-based platform has the potential for export to other systems.

Expert and Consumer Evaluation of Patient Medication Leaflets Provided in U.S. Pharmacies

OBJECTIVE

Evaluate the distribution and quality of patient medication leaflets provided in U.S. pharmacies.

DESIGN

Observational.

SETTING

United States.

PARTICIPANTS

384 randomly selected community pharmacies in 44 states.

INTERVENTIONS

Professional shoppers (acting as patients) presented four new prescriptions to study pharmacies.

MAIN OUTCOME MEASURES

Medication leaflets obtained by shoppers were evaluated by expert and consumer raters using criteria specified in federal law mandating distribution of useful written information to 95% of individuals receiving new prescriptions by 2006.

RESULTS

Leaflets were provided by pharmacies with 89% of 1,536 prescriptions presented by professional shoppers posing as patients. Leaflet quality varied: 95% of leaflets received high ratings on accuracy, but only 19% received high ratings on the specificity of directions. Fewer than 10% of all leaflets met quality criteria regarding contraindications, precautions, and how to avoid harm. One fourth of all leaflets had poor print size, according to the shoppers.

CONCLUSION

Additional efforts are needed to meet federally mandated information distribution and quality goals by 2006.

Health literacy among Spanish-speaking Latino parents with limited English proficiency

BACKGROUND

Health literacy measures the degree to which individuals understand health information. It has not been studied among parents with limited English proficiency (LEP).

OBJECTIVE

We aimed to determine how well Spanish-speaking Latino parents with LEP understood the written instructions accompanying a routinely prescribed medication.

DESIGN AND METHODS

We conducted a cross-sectional survey of parents of young children. We showed subjects a medicine bottle with an English prescription label and a Spanish drug information sheet (DIS). Subjects demonstrated how much medicine they would give and stated how often they would give it (Medication Dosing). Then they answered 5 questions regarding information from the DIS (DIS comprehension). We coded responses dichotomously as correct or incorrect. We compared Medication Dosing and DIS comprehension by age, comfort with speaking English, birthplace, number of years in the United States, and education. Regression analyses were performed to adjust for these potential confounders.

RESULTS

Of 100 participants, 22% correctly dosed the medication; 29% correctly answered all questions regarding the Spanish DIS. Of subjects comfortable speaking English, 50% correctly demonstrated the amount of medicine to give. Overall, higher education and comfort speaking English were associated with better Medication Dosing. Higher education and birth in South America were associated with better DIS comprehension.

CONCLUSIONS

Few parents with LEP were able to understand routinely dispensed written medication instructions. Pediatricians should not assume that Spanish-speaking Latino parents who are comfortable speaking English will understand a prescription label written in English, or that Latino parents who speak Spanish will understand drug information written in Spanish.

The Diabetes Continuity of Care Scale: the development and initial evaluation of a questionnaire that measures continuity of care from the patient perspective

The purpose of the present study was to develop and pilot test a questionnaire to assess continuity of care from the perspective of patients with diabetes. Seven patient and two healthcare-provider focus groups were conducted. These focus groups generated 777 potential items. This number was reduced to 56 items after item reduction, face validity testing and readability analysis, and to 47 items after a preliminary factor analysis. Readability was assessed as requiring 7-8 years of schooling. Sixty adult patients with diabetes completed the draft Diabetes Continuity of Care Scale (DCCS) at a single point in time to assess the validity of the instrument. Patients completed the draft DCCS again 2 weeks later to assess test-retest reliability. A provisional factor analysis and grouping according to clinical sense yielded five domains: access and getting care, care by doctor, care by other healthcare professionals, communication between healthcare professionals, and self-care. The internal consistency (Cronbach's alpha) for the whole scale was 0.89. The test-retest reliability was r = 0.73. The DCCS total score was moderately correlated with some of the measures used to establish construct validity. The DCCS could differentiate between patients who did and did not achieve specific process and clinical indicators of good diabetes care (e.g. Hba1c tested within 6 months). The development of the DCCS was centred on the patient's perspective and revealed that the patient perspective regarding continuity of care extends beyond the concept of seeing one doctor. Initial testing of this instrument demonstrates that it has promise as a reliable and valid measure in this area.

Professional and patient perspectives on nutritional needs of patients with cancer

PURPOSE/OBJECTIVES

To identify and compare perceptions of RNs, registered dietitians (RDs), and patients regarding the best format and key nutrition information components that should be provided to patients during cancer treatment.

DESIGN

Cross-sectional study using an opinion-based questionnaire.

SETTING

Outpatient cancer centers.

SAMPLE

506 RNs and 367 RDs, as well as 653 patients undergoing cancer treatment.

METHODS

Two similar self-administered questionnaires were developed, one for patients and one for healthcare professionals. Face and content validity were assessed by a panel of experts. Data were analyzed using descriptive statistics, chi-square statistic, and a Spearman Correlation Coefficient to compare responses.

MAIN RESEARCH VARIABLES

Patient nutrition concerns as well as format and content of printed educational materials.

FINDINGS

Significant differences existed among groups regarding the most common nutrition concerns, the perception of importance of information frequently provided to patients with cancer, and rank order of importance for eight items typically provided to patients. The dietary information format preferred by all groups was an all-inclusive booklet; RNs (75%) were more likely than RDs (43%) or patients (50%) to prefer this format. Data also revealed that almost half of the patients (47%) received no dietary counseling, including 18% who experienced significant weight loss.

CONCLUSIONS

RNs and RDs who provide nutrition education to patients with cancer should consider the need to develop and use a variety of printed materials to meet individual needs. Because major concerns of patients and healthcare professionals were related to patients ability to consume adequate amounts of food, this should be the primary focus of any nutrition education materials.

IMPLICATIONS FOR NURSING

These findings provide information that can be applied to the development of informational materials and counseling practices.

Empowering Providers to Meet Patient Information Needs

Recent studies on the effectiveness of patient information tools and methods confirm that what patients want and what they get are sometimes widely at odds. As the paternalistic notion of “compliance” is evolving into the patient-centred concept of “adherence,” new data and guidelines may help us to address our patients' wants and needs for medication information. This in turn supports patients in their own health and medication management.

A readability analysis of Australian stroke information

The aims of this study were to document the readability of a stroke education brochure and to illustrate how the readability of this document might be improved. Readability analyses using three different formulas were conducted on a stroke education brochure from the Australian National Stroke Foundation. Consistent with previous studies of the readability of written health information, results indicated that the overall level of difficulty of the material was too complex for the average member of the public to read and understand. Revision of a randomly selected section of text using established guidelines for writing patient information, and subsequent reanalysis of this section, showed that simple revisions of health literature can dramatically improve readability. Given the importance of effective communication of preventative information about stroke, we present these results as a model of how future revisions of difficult to read stroke-related literature might be conducted to improve public education.

Medication education for patients with epilepsy in Taiwan

The aim of this study is to evaluate the medication knowledge achieved by conventional verbal education and the influence of drug information leaflets in patients with epilepsy. Drug compliance and sources of information of the patients were also examined. Fifty-one adults in an epilepsy outpatient clinic participated this survey. These patients were asked to complete a questionnaire and to specify sources of drug information. Serum drug levels were checked and compared with the self-reported compliance. Then, drug information leaflets were given to patients. In the next follow-up visit, patients were asked to fill out the same questionnaire again. In the baseline assessment, 36 patients (70.6%) could accurately list their medications. However, half of patients were not knowledgeable about side effects and did not keep a seizure diary. After provision of drug leaflets, the epilepsy medication assessment score increased from 3.9 +/- 1.9 to 5.1 +/- 1.7 (P<0.001). In addition, patients reported being compliant most of the time and this matched drug levels. On average, each patient had 2.8 sources of information and 5 patients used Internet as a tool. Despite achieving good compliance, conventional verbal education did not sufficiently cover drug-related issues. Providing patients with written information apparently increase their medication knowledge and probably enhance seizure control.

Effect of pictograms on readability of patient information materials

OBJECTIVE

To design, develop, and evaluate a simple, understandable medicine label and patient information leaflet (PIL) for nystatin suspension, and to assess the effect of incorporating pictograms on understanding in low-literate participants.

METHODS

Patient information materials were designed and pretested in a pilot study (n = 20), and were subjected to the Fry's readability test. The final evaluation was conducted with 60 low-literate participants who had a maximum of 7 years of formal schooling and for whom English was their second language. Demographic data were collected. Participants were randomly allocated to a control (text-only information) or experimental (text + pictogram information) group, shown the medicine label and PIL, and asked to read them. A series of questions was asked about the instructions and an understanding level was calculated in each case. A second series of questions assessed patient acceptability of the materials. Differences in understanding were determined by chi(2) tests.

RESULTS

Both sets of these simple written materials were generally well understood. However, the presence of pictograms was shown to improve the comprehension of more complex information, resulting in significantly more participants in the experimental group obtaining a score for understanding >80% for both the medicine label and PIL. A clear preference for the materials incorporating pictograms was expressed.

CONCLUSIONS

The presence of pictograms had a positive effect in the acquisition and comprehension of drug information.

Evaluation of written prescription information provided in community pharmacies: a study in eight states

OBJECTIVES

To develop three tools for assessing the quality of written information provided with new prescriptions in community pharmacies and to identify pharmacy, pharmacist, and patient characteristics associated with the dissemination and quality of that information.

DESIGN

Observational study. Regression techniques were used to analyze the influence of pharmacy, pharmacist, and shopper (acting as patient) characteristics on outcome measures.

PARTICIPANTS

Trained shoppers (acting as patients) visited 306 randomly selected pharmacies in 8 states. Each shopper presented three prescriptions, answered questions according to a standard scenario, accepted the information offered, and paid for the prescriptions.

MAIN OUTCOME MEASURES

Percentage of shoppers receiving any written information; quality of written information as judged by an expert panel using explicit criteria.

RESULTS

Shoppers received an information leaflet with 87% of the 918 prescriptions dispensed. Although most leaflets provided unbiased information, leaflet length and quality of information varied greatly. A majority of leaflets did not include adequate information about contraindications, precautions, and how to avoid harm. Shoppers were more likely to receive leaflets in chain pharmacies and pharmacies with more staff. Information quality also was higher in chain pharmacies. Shopper and pharmacist demographic characteristics were unrelated to the level or quality of written information after controlling for other factors.

CONCLUSION

The provision of patient leaflets is becoming a routine practice in the states studied. However, most leaflets do not meet quality criteria. It is important for pharmacists to become familiar with criteria for evaluating these leaflets and to take necessary action to improve their quality.

Factors influencing consumer use of written drug information

OBJECTIVE

To provide an overview of the use and impact of written drug information (WDI) on consumers, and to review the literature on the factors influencing the use of WDI by consumers.

DATA SOURCES

Relevant articles published in English since the late 1970s were identified based on searches of on-line databases, texts, and cited references in published articles.

STUDY SELECTION

Articles reporting findings on the origin, use, and impact of WDI were included. Due to limited literature, articles reporting findings on factors influencing the use of written drug as well as disease information were included.

DATA EXTRACTION

Due to the lack of design consistency between studies and the comparatively small volume of work, subjective assessment rather than a criteria-based objective review was deemed more appropriate.

DATA SYNTHESIS

To date, research on WDI has focused on its use and impact. WDI has the potential to increase patients' knowledge, compliance, and satisfaction. However, there is also the potential for anxiety or premature cessation of therapy due to fear of possible adverse effects. Multiple factors may potentially influence the use of WDI by consumers including those associated with the written information document (readability, presentation), the patient (health literacy, role of caregiver, demographic factors, health locus of control, coping style, health belief model), and the environment (timing of provision, experience).

CONCLUSIONS

WDI has the potential to impact consumers positively and negatively. Although not widely investigated, a number of factors can potentially influence the use of WDI by consumers. The findings of this review can form the basis for much needed further research.

Using alternative methodologies for evaluating patient medication leaflets

A variety of direct and indirect methods have been used to evaluate written medication information; however, no published research has validated assessment tools or presented direct consumer assessment of patient information leaflets (PILs) provided in US community pharmacy (CP). We report on two new instruments: the medication information design assessment scale (MIDAS), an indirect measure of design quality administered by the investigators, and the consumer information rating form (CIRF), a direct measure of comprehensibility, utility, and overall design quality applied by a consumer panel. These were used to assess two types of PILs: 36 CP-PILs obtained from community pharmacies and 3 Model-PILs incorporating recommended design characteristics. The validity of the MIDAS was demonstrated in two ways. First, as predicted, the Model-PILs were rated more positively by consumers. We also found a significant positive correlation between the number of design criteria incorporated in a CP-PIL (as measured by the MIDAS score) and the consumers rating of design quality (CIRF). In conclusion, we confirmed the importance of design characteristics in the production of written medication information and have also developed and validated two easy-to-use tools for the assessment of written medication information.

[Do patients understand their prescribed antibiotic treatments?]

OBJECTIVE

To assess to what degree patients who had been prescribed an antibiotic understand the dose and duration of the prescription.

DESIGN

Descriptive, cross-sectional.

SETTING

Primary care in Toledo.

PARTICIPANTS

People over 18 who attended 10 pharmacies in Toledo with an antibiotic prescription in April and May 2000.

MAIN MEASUREMENTS

The prescriptions were dispensed by a pharmacist in charge at each establishment. After receipt of the prescription, the patient was asked about the dose of the drug prescribed. This was then compared with the instructions on the drug.

RESULTS

155 women and 163 men made up the sample, with an average age of 46.42 (SD, 17.2). The most commonly prescribed antibiotics were: a) amoxycillin (24.2%), 2) amoxycillin-clavulanic acid (18.2%), and c) ciprofloxacin (10.6%). 63.2% of those interviewed remembered correctly the dosage prescribed without having to consult any kind of instruction, whereas 17.6% did need to consult instructions. 33% brought instructions written by the doctor. The average age of those who answered incorrectly was 52.8; and of those who answered correctly, 44.9 (p < 0.01). There were no significant differences between men and women.

CONCLUSIONS

There is an important number of patients, especially older ones, who have not received or have not understood the instructions received from their doctor.