Evaluation of written medicine information: validation of the Consumer Information Rating Form

Development of an action plan for acute food protein-induced enterocolitis syndrome in Japan

Reports of food protein-induced enterocolitis syndrome (FPIES) in Japan have been increasing. However, the disease itself and the treatment options are poorly understood by both patients and medical professionals. The objective of this study is to develop an action plan for acute FPIES in Japan. We prepared a single-sheet action plan that describes the management of acute FPIES episodes for caregivers on one side and medical professionals on the reverse side. To evaluate the content of the action plan, we distributed a questionnaire to caregivers of patients with FPIES and to physicians who would encounter patients with FPIES. Changes to the FPIES action plan were made based on the feedback from the participants. The Delphi method was utilized to finalize the action plan. The participants of the initial survey found the action plan to be useful but the process for determining severity to be impractical. After discussion, the authors made appropriate improvements. By the Delphi method, consensus was reached on the revised FPIES action plan. In conclusion, this Japanese FPIES action plan was created by physicians from multiple subspecialties and caregivers of patients with FPIES. The action plan may improve the management of acute FPIES reactions in the Japanese community.

Content and Face Validity of the Evaluation Tool of Health Information for Consumers (ETHIC): Getting Health Information Accessible to Patients and Citizens

BACKGROUND

Health information concerns both individuals' engagement and the way services and professionals provide information to facilitate consumers' health decision making. Citizens' and patients' participation in the management of their own health is related to the availability of tools making health information accessible, thus promoting empowerment and making care more inclusive and fairer. A novel instrument was developed (Evaluation Tool of Health Information for Consumers-ETHIC) for assessing the formal quality of health information materials written in Italian language. This study reports ETHIC's content and face validity.

METHODS

A convenience sample of 11 experts and 5 potential users was involved. The former were requested to evaluate relevance and exhaustiveness, the latter both readability and understandability of ETHIC. The Content Validity Index (CVI) was calculated for ETHIC's sections and items; experts and potential users' feedback were analyzed by the authors.

RESULTS

All sections and most items were evaluated as relevant. A new item was introduced. Potential users provided the researchers with comments that partly confirmed ETHIC's clarity and understandability.

CONCLUSIONS

Our findings strongly support the relevance of ETHIC's sections and items. An updated version of the instrument matching exhaustivity, readability, and understandability criteria was obtained, which will be assessed for further steps of the validation process.

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.

Evaluation of Medicine Information Leaflets for Omeprazole, Safety Knowledge, and Perceptions of Taking the Medication in Thailand

PURPOSE

This study aimed to compare package inserts and patient information leaflets for omeprazole in terms of the quality of and satisfaction with the written medicine information, medication safety knowledge, and perceived benefits and risks.

PATIENTS AND METHODS

A cross-sectional, comparative study was conducted at a university hospital in Thailand. Outpatients visiting the pharmacy departments prescribed omeprazole were randomly selected to receive either a package insert or a patient information leaflet. Medication safety knowledge was measured using a set of eight questions. The quality of the written medicine information was measured by the Consumer Information Rating Form. Perceived benefits and risks of the medication were rated using a visual analog scale. Linear regression was used to determine factors associated with perceived benefits and risks.

RESULTS

Of the 645 patients, 293 agreed to answer the questionnaire. 157 and 136 patients were given patient information leaflets and package inserts, respectively. Most respondents were female (65.6%), over half had a degree (56.2%). Patients reading the patient information leaflets had slightly higher overall safety knowledge scores than those reading the package inserts (5.88 ± 2.25 vs 5.25 ± 1.84, p=0.01). Using the Consumer Information Rating Form, the patient information leaflets were given significantly higher scores compared to the package inserts for comprehensibility (19.34±3.92 vs 17.32±3.52, p<0.001) and design quality (29.25 ± 5.00 vs 23.81 ± 5.16, p<0.001). After reading the leaflets, patients receiving the patient information leaflets had significantly higher satisfaction with the information provided (p=0.003). In contrast, those receiving the package inserts rated the risks of omeprazole higher (p=0.007).

CONCLUSION

Demonstrable differences were found from the patient perspective between a package insert and a patient information leaflet for the same medicine, mostly in favour of patient information leaflets. Medicine safety knowledge after reading PI and PIL was similar. However, receiving package inserts provided higher perceived risks from taking the 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.

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 psychometric validation for evaluating written medicine information in Thailand: The Consumer Information Rating Form

OBJECTIVE

To translate and validate the consumer information rating form (CIRF) for use in Thai populations.

DESIGN

The development of the CIRF was carried out in two phases: translation process and cognitive interview, and psychometric testing.

SETTING

A university hospital and a tertiary hospital in northeast Thailand.

PARTICIPANTS

150 outpatients from medicine department: 30 for phase 1 and 120 patients for phase 2 study.

METHODS

The CIRF was translated with cultural adaptation into Thai using cognitive interview technique in a sample of outpatients. A larger sample of outpatients then completed the CIRF in relation to either a package insert (PI) or a patient information leaflet (PIL) for one of three medicines: atorvastatin, celecoxib and metformin. Construct validity was assessed using principal component analysis (PCA) and internal consistency using Cronbach's α coefficient. Known group validity was assessed by comparing mean consumers' ratings for PIs and PILs.

RESULTS

Thirty participants engaged in the cognitive interview and 120 participants completed the CIRF. The PCA found the 17 items of the CIRF were extracted into three factors: comprehensibility, utility and design quality scales, mirroring the original. Cronbach's α for the overall scale (0.904) indicated good internal consistency. Known-group validity demonstrated significant differences in consumers' rating between PIs and PILs for almost all items (p<0.001).

CONCLUSION

Thai version of CIRF had acceptable validity and reliability for Thai consumers' ratings of written medicine information. The CIRF could be of practical use in the process of developing medicine information to ensure consumers' comprehension and their usefulness.

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.

Differences in Memory, Perceptions, and Preferences of Multimedia Consumer Medication Information: Experimental Performance and Self-Report Study

Background

Electronic health resources are becoming prevalent. However, consumer medication information (CMI) is still predominantly text based. Incorporating multimedia into CMI (eg, images, narration) may improve consumers’ memory of the information as well as their perceptions and preferences of these materials.

Objective

This study examined whether adding images and narration to CMI impacted patients’ (1) memory, (2) perceptions of comprehensibility, utility, or design quality, and (3) overall preferences.

Methods

We presented 36 participants with CMI in 3 formats: (1) text, (2) text + images, and (3) narration + images, and subsequently asked them to recall information. After seeing all 3 CMI formats, participants rated the formats in terms of comprehensibility, utility, and design quality, and ranked them from most to least favorite.

Results

Interestingly, no significant differences in memory were observed (F_2,70=0.1, P=0.901). Thus, this study did not find evidence to support multimedia or modality principles in the context of CMI. Despite the absence of effects on memory, the CMI format significantly impacted perceptions of the materials. Specifically, participants rated the text + images format highest in terms of comprehensibility (χ²₂=26.5, P<.001) and design quality (χ²₂=35.69, P<.001). Although the omnibus test suggested a difference in utility ratings as well (χ²₂=8.21, P=.016), no significant differences were found after correcting for multiple comparisons. Consistent with perception findings, the preference ranks yielded a significant difference (χ²₂=26.00, P<.001), whereby participants preferred the text + images format overall. Indeed, 75% (27/36) of participants chose the text + images format as their most favorite. Thus, although there were no objective memory differences between the formats, we observed subjective differences in comprehensibility, design quality, and overall preferences.

Conclusions

This study revealed that although multimedia did not appear to influence memory of CMI, it did impact participants’ opinions about the materials. The lack of observed differences in memory may have been due to ceiling effects, memory rather than understanding as an index of learning, the fragmented nature of the information in CMI itself, or the size or characteristics of the sample (ie, young, educated subjects with adequate health literacy skills). The differences in the subjective (ie, perceptions and preferences) and objective (ie, memory) results highlight the value of using both types of measures. Moreover, findings from this study could be used to inform future research on how CMI could be designed to better suit the preferences of consumers and potentially increase the likelihood that CMI is used. Additional research is warranted to explore whether multimedia impacts memory of CMI under different conditions (eg, older participants, subjects with lower levels of health literacy, more difficult stimuli, or extended time for decay).

The Canadian anaphylaxis action plan for kids: development and validation

OBJECTIVES

We designed a written Canadian Anaphylaxis Action Plan for Kids (Kids' CAP) which incorporates validated pictograms with written instructions. Using a patient-centered approach, we aimed to validate the Kids' CAP and assess its impact on anaphylaxis recognition and treatment, and to determine its' perceived usefulness.

PATIENT INVOLVEMENT

Children and their parents were involved in appraising the design and written contents of the Kids' CAP.

METHODS

The design process consisted of a development phase and clinical validation phase. First, we assessed the readability and understandability of the Kids' CAP using validated instruments. Then, patients (12-17 years of age) and parents of patients (<12 years of age) were given the Kids' CAP during the first consultation with allergy specialists or an Emergency Department visit for anaphylaxis. Subsequently, we conducted a phone interview 2-3 weeks later to assess their comprehension of anaphylaxis management. We also used the Consumer Information Rating Form to measure the participants' perception of the design quality and usefulness of the Kids' CAP.

RESULTS

Of the 230 participants enrolled, 205 (89%) completed the follow-up interview. The written contents of the Kid's CAP were modified to match grade 7 readability level. The total mean score of the Consumer Information Rating Form for comprehensibility was 23.1 (SD 2.4), and 25.1 (SD 2.3) for design quality. The mean comprehension score was 11.3 (SD 1.8) (reference range 0-12), with no significant difference between participants with and without previous experience with anaphylaxis, or high vs. low literacy level.

CONCLUSION

Engaging children and parents in the design and contents of written anaphylaxis action plan is an innovative approach to produce a useful document for the end-users.

PRACTICE IMPLICATIONS

The Kids' CAP is a valid tool that can be used in emergency departments and allergy clinics to improve patient's comprehension of anaphylaxis manifestations and treatment.

Improving Patient Education Materials: A Practical Algorithm from Development to Validation

Objectives

To generate an algorithm for systematic development and validation of written patient information in accordance with well-established and validated psychometric and statistical methods that can be applied to different fields of medicine.

Methods

A literature search was carried out in PubMed and Google Scholar. Methods were selected and combined to an algorithm. Feasibility and practicability is tested by the development of patient education materials on "ureteral stenting".

Results

The algorithm includes 4 study phases. After internal audit expert, readability of the first version is objectified using the Flesch Reading Ease formula. This draft is tested by a few patients performing semi-structured interviews using "The think aloud method" by Someren et al. Content validity is evaluated by a written survey by external consultants in accordance with Lawshe's "Quantitative approach to content validity". The final leaflet is developed at a consensus meeting and validated by patients based on the Consumer Information Rating Form. The new algorithm could be tested by the development of patient education materials on "ureteral stenting" as a test run.

Conclusion

We developed an algorithm for systematic development and validation of written patient information in accordance with well-established, validated psychometric and statistical methods. This algorithm can be applied to arbitrary fields of medicine.

Validation of a new tool for evaluating subjects' satisfaction with medicine package leaflets: a cross-sectional descriptive study

BACKGROUND

Package leaflets of medicines need to be intelligible, but tools for their evaluation are scarce.

OBJECTIVE

To validate a new tool for assessing subjects' satisfaction with medicine package leaflets (LiS-RPL).

DESIGN AND SETTING

Cross-sectional descriptive study conducted in two regions of Portugal (Lisbon and Centre).

METHODS

503 participants (53.1% male) were selected according to convenience and homogenously distributed into three groups: 1 to 6; 7 to 12; and > 12 years of schooling. LiS-RPL was developed based on international regulation guidelines and was initially composed of 14 items. Twelve package leaflets were tested. Dimensionality calculations included: exploratory factor analysis and minimum rank factor analysis; Kaiser-Meyer-Olkin index and Bartlett's sphericity test to assess matrix adequacy for exploratory factor analysis; exploratory bifactor analysis with Schmid-Leiman solution to detect possible existence of a broad second-order factor; and Bentler's Simplicity Index and Loading Simplicity Index to assess factor simplicity. Diverse coefficients were calculated to assess reliability.

RESULTS

Minimum rank factor analysis detected a two-factor or single-factor structure. Exploratory factor analysis with 12 items showed a two-factor structure, explaining 69.11% of the variance. These items were strongly correlated with each other (r = 0.80). Schmid-Leiman: all items seemed to represent the general factor (loadings above 0.50), which was 76.4% of the extracted variance. Simplicity indices were good (percentile 99): Bentler's Simplicity Index of 0.99 and Loading Simplicity Index of 0.48. Internal consistency indexes indicated good reliability. LiS-RPL was shown to be homogenous.

CONCLUSION

LiS-RPL is a validated tool for evaluating subjects' satisfaction with medicine package leaflets.

Comparing responses to differently framed and formatted persuasive messages to encourage help-seeking for depression in Japanese adults: a cross-sectional study with 2-month follow-up

OBJECTIVE

To examine audience's responses to differently framed and formatted persuasive messages in the context of developing depression help-seeking messages.

DESIGN

Cross-sectional followed by 2-month follow-up study.

SETTING AND PARTICIPANTS

A web-based survey was conducted in July 2017 among Japanese adults aged 35-45 years. There were 1957 eligible respondents without psychiatric history. Of these, 1805 people (92.2%) completed the 2-month follow-up questionnaire.

MAIN OUTCOME MEASURES

Six depression help-seeking messages were prepared with three frames (neutral, loss and gain framed)×2 formats (formatted and unformatted). Participants were asked to rate one of the messages in terms of comprehensibility, persuasiveness, emotional responses, design quality and intended future use. Help-seeking intention for depression was measured using vignette methodology before and after exposure to the messages. Subsequent 2-month help-seeking action for their own mental health (medical service use) was monitored by the follow-up survey.

RESULTS

The loss-framed messages more strongly induced negative emotions (surprise, fear, sadness and anxiety), while the gain-framed messages more strongly induced a positive emotion (happiness). The message formatting applied the Centres for Disease Control and Prevention Clear Communication Index, enhanced the emotional responses and increased the likelihood that the message will be read. The loss-framed formatted message alone had a significantly greater OR of having help-seeking intention for depression compared with the neutral-framed unformatted message as a reference group. All messages had little impact on maintaining help-seeking intention or increasing help-seeking action.

CONCLUSION

Message framing and formatting may influence emotional responses to the depression help-seeking message, willingness to read the message and intention to seek help for depression. It would be recommendable to apply loss framing and formatting to depression help-seeking messages, to say the least, but further studies are needed to find a way to sustain the effect of messaging for a long time.

Consumer satisfaction with National Alliance on Mental Illness written medicine information

Introduction

Written medicine information (WMI) is a collection of facts for a specific medication, and it helps facilitate patient understanding of medication therapy. The primary objective of this study was to assess consumer satisfaction with National Alliance on Mental Illness (NAMI) WMI. A secondary objective was to assess health care professional satisfaction.

Methods

National Alliance on Mental Illness WMI and surveys were offered to consumers, health care professionals, and trainees at 3 treatment centers with psychiatric services. All adults who received medication counseling were eligible for inclusion. Survey responses were evaluated using descriptive statistics.

Results

Most consumers (82.4%) and providers (74.5%) reported overall satisfaction with NAMI WMI. Consumers were least satisfied with information on how to manage unwanted effects, drug-drug interactions, and readability (9.5%, 14.9%, 41.9% dissatisfaction).

Discussion

Evaluation and feedback from consumers and health care professionals may influence decisions to refine NAMI WMI to meet consumer needs.

Perceived effectiveness rating scales applied to insomnia help-seeking messages for middle-aged Japanese people: a validity and reliability study

BACKGROUND

Communicating health messages is an important way to influence people's behaviors towards health issues. Providers need to incorporate audience's perspective to design more persuasive messages. This study aimed to develop rating scales for measuring audience's perception of effectiveness of health messages in Japanese people.

METHODS

The comprehensibility scale including five items and the persuasiveness scale including seven items were designed based on literature review. A cross-sectional web-based survey was conducted among Japanese adults aged 35-45 years to assess the reliability and validity of the scales. Participants were asked to rate a text message that encouraged help-seeking intention for insomnia. All scale items were scored on a 1-to-5 point Likert scale, and they were averaged to produce an overall score for each scale.

RESULTS

Explanatory factor analysis revealed a two-factor solution that agreed with the comprehensibility and persuasiveness scales, respectively. Correlation coefficients between each set of items ranged between 0.63-0.87 for the comprehensibility scale and 0.37-0.76 for the persuasiveness scale. Cronbach alpha (0.88) indicated satisfactory internal consistency of the set of items. The mean (SD) of the comprehensibility and persuasiveness scores were 3.70 (0.82) and 3.15 (0.61), respectively, without ceiling or floor effects. These scores were significantly associated with intended future use of the message. The proportion of participants who reported a positive help-seeking intention for insomnia was significantly higher in the higher score groups for both scales. Multiple logistic regression analysis showed that the comprehensibility and persuasiveness scores were significantly associated with the help-seeking intention for insomnia.

CONCLUSION

The proposed rating scales exhibited adequate reliability and validity for measuring the comprehensibility and persuasiveness of insomnia health-seeking message in middle-aged Japanese people. Further studies are needed to confirm the generalizability of the results, but these scales may be useful for pretesting a health message with audience members to make it more acceptable and persuasive to the intended audience.

TRIAL REGISTRATION

Not applicable; this is not a report of intervention trial.

Australian mental health consumers and carers expect more health management information from community pharmacy

OBJECTIVE

To identify the health management information needs of Australian mental health consumers and carers and explore the role of community pharmacy in meeting those needs.

METHOD

Interviews and focus groups were conducted with a purposive convenience sample of 74 mental health consumers and carers across three Australian states, representing metropolitan, rural and remote settings, including those with culturally and linguistically diverse backgrounds. Recruitment and interviews continued until data saturation was reached. Interviews and group discussions were digitally recorded and transcribed verbatim, and data were managed using NVivo^® software. A 'coding framework' or set of themes was created, and all transcripts were coded accordingly. Thematic analysis was informed by a general inductive approach.

RESULTS

Participants had unmet needs for information from community pharmacy. They expressed the requirement for receiving easy-to-understand, relevant medication information about mental health management from community pharmacy staff, communicated in a respectful way, with clear and comprehensive medication labelling, while respecting consumer privacy.

CONCLUSION

The information needs of mental health consumers and carers remain largely unmet within Australian community pharmacy. This was particularly evident regarding the provision of information about adverse effects of medicines. The overall perceived lack of information is experienced as disempowering.

PRACTICE IMPLICATIONS

Australian community pharmacy is well placed to respond to the unmet demand for information needs of mental health consumers and carers. While many community pharmacies are embracing the principles of patient-centred care, there is an opportunity to optimise the quality of care provided to mental health consumers and carers.

Readability of patient education materials in ophthalmology: a single-institution study and systematic review

Background

Patient education materials should be written at a level that is understandable for patients with low health literacy. The aims of this study are (1) to review the literature on readability of ophthalmic patient education materials and (2) to evaluate and revise our institution’s patient education materials about glaucoma using evidence-based guidelines on writing for patients with low health literacy.

Methods

A systematic search was conducted on the PubMed/MEDLINE database for studies that have evaluated readability level of ophthalmic patient education materials, and the reported readability scores were assessed. Additionally, we collected evidence-based guidelines for writing easy-to-read patient education materials, and these recommendations were applied to revise 12 patient education handouts on various glaucoma topics at our institution. Readability measures, including Flesch-Kincaid Grade Level (FKGL), and word count were calculated for the original and revised documents. The original and revised versions of the handouts were then scored in random order by two glaucoma specialists using the Suitability Assessment of Materials (SAM) instrument, a grading scale used to evaluate suitability of health information materials for patients. Paired t test was used to analyze changes in readability measures, word count, and SAM score between original and revised handouts. Finally, five glaucoma patients were interviewed to discuss the revised materials, and patient feedback was analyzed qualitatively.

Results

Our literature search included 13 studies that evaluated a total of 950 educational materials. Among the mean FKGL readability scores reported in these studies, the median was 11 (representing an eleventh-grade reading level). At our institution, handouts’ readability averaged a tenth-grade reading level (FKGL = 10.0 ± 1.6), but revising the handouts improved their readability to a sixth-grade reading level (FKGL = 6.4 ± 1.2) (p < 0.001). Additionally, the mean SAM score of our institution’s handouts improved from 60 ± 7 % (adequate) for the original versions to 88 ± 4 % (superior) for the revised handouts (p < 0.001).

Conclusions

Our systematic review of the literature reveals that ophthalmic patient education materials are consistently written at a level that is too high for many patients to understand. Our institution’s experience suggests that applying guidelines on writing easy-to-understand material can improve the readability and suitability of educational materials for patients with low health literacy.

How to Test Mandatory Text Templates: The European Patient Information Leaflet

The structure of patient information leaflets (PILs) supplied with medicines in the European Union is largely determined by a regulatory template, requiring a fixed sequence of pre-formulated headings and sub-headings. The template has been criticized on various occasions, but it has never been tested with users. This paper proposes an alternative template, informed by templates used in the USA and Australia, and by previous user testing.The main research question is whether the revision better enables users to find relevant information. Besides, the paper proposes a methodology for testing templates. Testing document templates is complex, as they are “empty”. For both the current and the alternative template, we produced a document with bogus text and real headings (reflecting the empty template) and a real-life document with readable text (reflecting the “filled” template). The documents were tested both in Dutch and in English, with 64 British and 64 Dutch users. The test used a set of scenario questions that covers the full range of template (sub)topics; users needed to indicate the text locations where they expected each question to be answered. The revised template improved findability of information; this effect was strongest for the “filled” template with readable text. When participants were shown both filled templates, there was a clear preference for the revised template. A closer analysis of the findability data revealed question-specific effects of topic grouping, topic ordering, subtopic granularity and wording of headings. Most of these favoured the revised template, but our revision led to adverse effects as well, for instance in the new heading Check with your doctor. Language-specific effects showed that the wording of the headings is a delicate task. Generally, we conclude that document template designs can be analyzed in terms of the four parameters grouping, ordering, granularity and wording. Furthermore, they need to be tested on their effects on information findability, with template translations requiring separate testing. The methodology used in this study seems an appropriate one for such tests. More specifically, we find that the new patient information leaflet template proposed here provides better information findability.

Usefulness scale for patient information material (USE) - development and psychometric properties

Background

One economical way to inform patients about their illness and medical procedures is to provide written health information material. So far, a generic and psychometrically sound scale to evaluate cognitive, emotional, and behavioral aspects of the subjectively experienced usefulness of patient information material from the patient’s perspective is lacking. The aim of our study was to develop and psychometrically test such a scale.

Methods

The Usefulness Scale for Patient Information Material (USE) was developed using a multistep approach. Ultimately, three items for each subscale (cognitive, emotional, and behavioral) were selected under consideration of face validity, discrimination, difficulty, and item content.

The final version of the USE was subjected to reliability analysis. Structural validity was tested using confirmatory factor analysis, and convergent and divergent validity were tested using correlation analysis. The criterion validity of the USE was tested in an experimental design. To this aim, patients were randomly allocated to one of two groups. One group received a full version of an information brochure on depression or chronic low back pain depending on the respective primary diagnosis. Patients in the second group received a reduced version with a lower design quality, smaller font size and less information.

Patients were recruited in six hospitals in Germany. After reading the brochure, they were asked to fill in a questionnaire.

Results

Analyzable data were obtained from 120 questionnaires. The confirmatory factor analysis supported the structural validity of the scale. Reliability analysis of the total scale and its subscales showed Cronbach’s α values between .84 and .94. Convergent and divergent validity were supported. Criterion validity was confirmed in the experimental condition. Significant differences between the groups receiving full and reduced information were found for the total score (p<.001) and its three subscales (cognitive p<.001, emotional p=.001, and behavioral p<.001), supporting criterion validity.

Conclusions

We developed a generic scale to measure the subjective usefulness of written patient information material from a patient perspective. Our construct is defined in line with current theoretical models for the evaluation of written patient information material. The USE was shown to be a short, reliable and valid psychometric scale.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-015-0153-7) contains supplementary material, which is available to authorized users.

Reading comprehension of health checkup reports and health literacy in Japanese people

OBJECTIVES

To determine the reading comprehension of health checkup reports in the context of health literacy (HL) in Japanese people.

METHODS

A web-based survey was conducted among 424 Japanese adults aged 35-59 years. Participants were asked to read specifically designed health checkup reports and then answer a series of questions to examine whether they accomplished the fundamental purposes of health checkup reports (recognition of the problems, recognition of the risk of illness, recognition of the need for preventive action, and motivation for preventive action). HL was simultaneously measured using the 14-item health literacy scale (HLS-14), the 11-item Lipkus scale (Lipkus-J), and the Newest Vital Sign (NVS-J).

RESULTS

About 70 % of the study subjects misread the normal/abnormal classification for at least one items. Those with lower HLS-14 scores were significantly less likely to recognize the problems, the risk of illness, and the need for preventive action for the examinee, and also less likely to express their willingness to take preventive action in compliance with the doctor's advice after having received the health checkup report. Compared with the HLS-14 scores, the Lipkus-J and NVS-J scores showed hardly any association with the reading comprehension of health checkup reports.

CONCLUSION

All examinees do not always have an adequate level of HL. HL may be the major determinant of reading comprehension of health checkup reports. For more effective health checkups, health promotion service providers should become aware of the existence of examinees with inadequate HL and address the problem of misreading health checkup results.

Enhancing provision of written medicine information in Australia: pharmacist, general practitioner and consumer perceptions of the barriers and facilitators

BACKGROUND

Written medicine information can play an important role in educating consumers about their medicines. In Australia, standardised, comprehensive written information known as Consumer Medicine Information (CMI) is available for all prescription medicines. CMI is reportedly under-utilised by general practitioners (GPs) and community pharmacists in consultations, despite consumer desire for medicine information. This study aimed to determine consumers', GPs' and community pharmacists' preferences for CMI provision and identify barriers and facilitators to its use.

METHOD

Structured questionnaires were developed and administered to a national sample of Australian consumers (phone survey), community pharmacists and GPs (postal surveys) surrounding utilisation of CMI. Descriptive and comparative analyses were conducted.

RESULTS

Half of consumers surveyed wanted to receive CMI for their prescription medicine, with spoken information preferable to written medicine information for many consumers and healthcare professionals. GPs and pharmacists remained a preferred source of medicine information for consumers, although package inserts were appealing to many among all three cohorts. Overall pharmacists were the preferred provider of CMI primarily due to their medicine expertise, accessibility and perceived availability. GPs preferred CMI dissemination through both the GP and pharmacist. Some consumers preferred GPs as the provider of medicines information because of their knowledge of the patients' medicines and/or medical history, regularity of seeing the patient and good relationship with the patient. Common barriers to CMI provision cited included: time constraints, CMI length and perceptions that patients are not interested in receiving CMI. Facilitators to enhance provision included: strategies to increase consumer awareness, longer consultation times and counseling appointments, and improvements to pharmacy software technology and workflow.

CONCLUSION

Medicine information is important to consumers, whether as spoken, written or a combination of both. A tailored approach is needed to ascertain individual patient preference for delivery and scope of medicine information desired so that appropriate information is provided. The barriers of time and perceived attitudes of healthcare practitioners present challenges which may be overcome through changes to workplace practices, adoption of identified facilitators, and education about the positive benefits of CMI as a tool to engage and empower patients.

Pharmacist, general practitioner and consumer use of written medicine information in Australia: are they on the same page?

BACKGROUND

Providing written medicine information to consumers enables them to make informed decisions about their medicines, playing an important role in educating and improving health literacy. In Australia, standardized written medicine information called Consumer Medicine Information (CMI) is available for medicines as package inserts, computer prints, or leaflets. Consumers want and read CMI, but may not always ask for it. General practitioners (GPs) and pharmacists are an important source of written medicine information, yet may not always provide CMI in their practice.

OBJECTIVE

To examine and compare the awareness, use and provision of CMI by consumers, pharmacists and general practitioners (GPs).

METHODS

Based on previous studies, structured questionnaires were developed and administered to a national sample of consumers (phone survey); community pharmacists and GPs (postal surveys) about utilization of CMI. Descriptive, comparative and logistic regression analyses were conducted.

RESULTS

The respondents comprised of 349 pharmacists, 181 GPs and 1000 consumers. Two-thirds of consumers, nearly all (99%) pharmacists and 90% of GPs were aware of CMI. About 88% of consumers reported receiving CMI as a package insert, however most pharmacists (99%) and GPs (56%) reported providing computer-generated CMI. GPs' and pharmacists' main reason for providing CMI was on patient request. Reasons for not providing were predominantly because consumers were already taking the medicine, concerns regarding difficulty understanding the information, or potential non-adherence. Of the 691 consumers reportedly reading CMI, 35% indicated concerns after reading. Factors associated with reading included gender, type of CMI received and frequency of provision.

CONCLUSION

Consumers want and read information about their medicines, especially when received from their GP or pharmacist. Healthcare professionals report usually discussing CMI when providing it to patients, although continued improvements in dissemination rates are desirable. Regular use of CMI remains a challenge, and ongoing strategies to promote CMI use are necessary to improve uptake of CMI in Australia.

The comprehensibility of health education programs: questionnaire development and results in patients with chronic musculoskeletal diseases

OBJECTIVE

The objective was to develop a comprehensive questionnaire for measuring the patient-perceived comprehensibility of health education programs (COHEP questionnaire). According to a conceptual model outlined in the article, comprehensibility is considered a context factor of patient health literacy.

METHODS

A questionnaire study was carried out on N=577 patients with chronic musculoskeletal diseases. During inpatient rehabilitation, patients participated in standardized, interactive group education programs conducted by clinic personnel. Factorial structure, unidimensionality, reliability, fit to the Rasch model, and construct validity were tested.

RESULTS

The COHEP consists of 30 items and 4 scales (comprehension-fostering behavior of program trainers, transferability to everyday life, comprehensibility of medical information, amount of information). All scales are reliable, unidimensional, and meet the requirements of the Rasch model. In addition, there are initial indications of validity. The descriptive results show that the overall rating of the comprehensibility of patient education programs in the German rehabilitation system is good, but that there are clear differences between centers.

CONCLUSION

The COHEP can be used to evaluate health education programs, since it measures an important proximal outcome.

PRACTICE IMPLICATIONS

An analysis of patient-perceived comprehensibility can help providers adapt education sessions better to the health literacy of patients.

Quality evaluation of JAMA Patient Pages on diabetes using the Ensuring Quality Information for Patient (EQIP) tool

CONTEXT

Many medical journals provide patient information leaflets on the correct use of medicines and/or appropriate lifestyles. Only a few studies have assessed the quality of this patient-specific literature.

OBJECTIVE

The purpose of this study was to evaluate the quality of JAMA Patient Pages on diabetes using the Ensuring Quality Information for Patient (EQIP) tool.

METHOD

A multidisciplinary group of 10 medical doctors analyzed all diabetes-related Patient Pages published by JAMA from 1998 to 2010 using the EQIP tool. Inter-rater reliability was assessed using the percentage of observed total agreement (p(o)). A quality score between 0 and 1 (the higher score indicating higher quality) was calculated for each item on every page as a function of raters' answers to the EQIP checklist. A mean score per item and a mean score per page were then calculated.

DATA SUMMARY

We found 8 Patient Pages on diabetes on the JAMA web site. The overall quality score of the documents ranged between 0.55 (Managing Diabetes and Diabetes) and 0.67 (weight and diabetes). p(o) was at least moderate (>50%) for 15 of the 20 EQIP items. Despite generally favorable quality scores, some items received low scores. The worst scores were for the item assessing provision of an empty space to customize information for individual patients (score=0.01, p(o)=95%) and patients involvement in document drafting (score=0.11, p(o)=79%).

CONCLUSIONS

The Patient Pages on diabetes published by JAMA were found to present weak points that limit their overall quality and may jeopardize their efficacy. We therefore recommend that authors and publishers of written patient information comply with published quality criteria. Further research is needed to evaluate the quality and efficacy of existing written health care information.

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.

Improving the usability of patient information leaflets

OBJECTIVE

This study assesses the usability of three patient information leaflets and attempts to improve them while complying with the current EU regulations.

METHODS

Three original leaflets were tested among 154 potential users. Every participant answered 15 scenario questions for one of the leaflets. The leaflets were subsequently redesigned based on the test results and evidence-based Document Design principles. The revised texts were tested among 164 participants.

RESULTS

All three original leaflets suffered from usability problems, especially problems related to finding relevant information. On average, only 75% of the topics could be located. Comprehension of the information, once found, was around 90%. The revisions led to better performance. Information was found faster and more successful. Comprehension scores were higher as well. A follow-up study shows that these findings can be generalized over paper formats.

CONCLUSION

Although the current EU regulations for patient information leaflets do not guarantee leaflet usability, the leaflets can be improved somewhat within the regulations. However, further research should evaluate the text structure currently imposed on leaflets.

PRACTICAL IMPLICATIONS

Information leaflets must be written, or rewritten, according to Document Design principles. Furthermore, they must be user tested in a rigorous way.

Recent Publications on Medications and Pharmacy

Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest will be abstracted monthly regarding a broad scope of topics.