A study of patients' self-interpretation of prescription instructions

Strategies to optimize comprehension of numerical medication instructions: A systematic review and concept map

OBJECTIVE

To develop evidence-based recommendations for improving comprehension of quantitative medication instructions.

METHODS

This review included a literature search from inception to November 2021. Studies were included for the following: 1) original research; 2) compared multiple formats for presenting quantitative medication information on dose, frequency, and/or time; 3) included patients/lay-people; 4) assessed comprehension-related outcomes quantitatively. To classify the studies, we developed a concept map. We weighed 3 factors (risk of bias in individual studies, consistency of findings among studies, and homogeneity of the interventions tested) to generate 3 levels of recommendations.

RESULTS

Twenty-one studies were included. Level 1 recommendations are: 1) use visualizations of medication doses for liquid medications, and 2) express instructions in time-periods rather than times per day. Level 2 recommendations include: validate icons, use panels or tables with explanatory text, use visualizations for non-English speaking populations and for those with low health literacy and limited English proficiency.

CONCLUSIONS

Visualized liquid medication doses and time period-based administration instructions improve comprehension of numerical medication instructions. Use of visualizations for those with limited health literacy and English proficiency could result in improved outcomes.

PRACTICE IMPLICATIONS

Practitioners should use visualizations for liquid medication instructions and time period-based instructions to improve outcomes.

Development and evaluation of a survey tool to explore patients' perceptions of their prescribed drugs and their need for drug information

Objective

To explore the effect of providing information about their prescribed drugs on patients' perceptions and use of the drugs.

Method

A survey tool was administered to 501 general medical patients in their own homes during a trial to reduce discrepancies between supplies of hospital prescribed drugs and those received in the community following hospital discharge. The patient sample was randomly recruited into two cohorts: 264 in the intervention group (given information regarding drugs prescribed on discharge from hospital to take to their community pharmacy) and 237 in the comparison group. Responses to the survey were explored to assess any effects on patients of providing such information.

Setting

Domiciliary visits to general medical patients in East London.

Key findings

The survey tool was subjected to factor analysis and reliability testing. Principal components analysis (PCA) was used to extract five factors that described an intrinsic desire for information, perceived impact of the illness, perceived utility of medicines, anxiety about illness and worry about changes to medicines. Internal consistency was good, ranging from 0.8 to 0.91 (Cronbach's coefficient alpha). Interconstruct relationships between the scales, patient demographics and the two cohorts were explored. The findings indicated that the degree of patient empowerment is related to two constructs: “intrinsic desire for information” and “worry about changes to medicines.” Patients who expressed a low degree of worry about changes and a high desire for information about their drugs seemed less worried and more empowered when given additional information. Conversely, those who expressed worries about changes in their medicines and did not want information about their medicines (were happy knowing little) seemed more worried and less empowered when given additional information about those changes.

Conclusion

Further exploration of relationships between patient perceptions and information provision is needed to influence appropriately the development of pharmaceutical care between hospital and community.

Use of pictorial aids in medication instructions: a review of the literature

PURPOSE

The effects of pictorial aids in medication instructions on medication recall, comprehension, and adherence are reviewed.

SUMMARY

Many patients depend on medication labels and patient information leaflets for pertinent drug information, but these materials are often difficult for patients to understand. Research in psychology and marketing indicates that humans have a cognitive preference for picture-based, rather than text-based, information. Studies have shown that pictorial aids improve recall, comprehension, and adherence and are particularly useful for conveying timing of doses, instructions on when to take medicine, and the importance of completing a course of therapy. Other research has compared various techniques for using picture-based information and supports the use of integrative instructions, a combination of textual, oral, and pictorial communication, to promote comprehension and adherence. While pictures have generally proven useful for improving patient comprehension and adherence, not all picture-based interventions have produced successful results. Some icons, particularly clock icons, have been found to be too complex to enhance understanding and could not overcome the advantage provided by the familiarity of the textbased format, suggesting that patients be trained to use pictorial medication information before they are expected to use icons as an aid for medication administration. In addition to enhancing understanding, pictorial aids have been found to improve patients' satisfaction with medication instructions.

CONCLUSION

The use of pictorial aids enhances patients' understanding of how they should take their medications, particularly when pictures are used in combination with written or oral instructions.

Medicine labels incorporating pictograms: do they influence understanding and adherence?

The objective was to determine the influence of medicine labels incorporating pictograms on the understanding of instructions and on adherence. Eighty-seven Xhosa participants attending an outpatient clinic who had been prescribed a short course of antibiotics were randomly allocated to either a control group (41 participants given text-only labels), or an experimental group (46 participants given text + pictogram labels). All participants had a maximum of 10 years of formal schooling. Follow-up home visits were conducted after 3-5 days to assess understanding of instructions and to evaluate adherence. A high adherence of greater than 90% was found for 54% of the experimental group, compared with only 2% of the control group. Average percentages for understanding in the control and experimental groups were 70 and 95%, respectively, and average adherence was 72 and 90%, respectively. The presence of pictograms was found to contribute positively to both understanding of instructions and adherence.

State Prescription Label Requirements in the United States

Objective:

To determine the current legal requirements for prescription labels and to explore the usefulness of this information in determining the utility of a standardized prescription label.

Data Sources:

State prescription label regulations were requested from Board of Pharmacy executives.

Study Selection:

Label requirements for prescriptions dispensed in community, noninstitutional pharmacies were selected for review.

Data Extraction:

Data were compiled, sorted by state, and analyzed as either federally mandated or additional state requirements. Additional state requirements were divided into 16 categories and analyzed by category.

Data Synthesis:

Responses were received from all 50 states. Five states did not list all federal label requirements. Medication name was the most frequently added requirement, followed by medication strength and name of manufacturer if the medication was generic. Only in New Jersey are pharmacists allowed to add directions not included in the prescription.

Conclusions:

States were consistent in the proper use of federal prescription label requirements. However, there was little agreement on what additional information should appear on the label. Nevertheless, there appears to be consensus for the name of the medication to be on the label. There also appears to be fairly strong consensus that medication strength and quantity should appear on the label. There is little interest in expanding the current directions-for-use requirement. Finally, the results support the utility of a standardized prescription label format.

Patients' use of health-teaching materials at three readability levels

The extent to which patients use and learn from drug literature written at three different readability levels was examined. A two-way analysis of variance showed an interaction effect on knowledge score between the readability level of the leaflet and the amount of schooling subjects reported: persons with higher education learned most from the hardest pamphlet and persons with the least formal education learned the most from the easiest pamphlet. A similar interaction was found in testing the likelihood that patients had read the leaflet. The results suggest that persons with little formal education would benefit from teaching materials with a readability level considerably lower than even many "easy-to-read" health-teaching materials available today.

Social pharmacology: unresolved critical issues

This article describes and analyzes decision-making by patients, physicians, and drug information providers about registered medical drugs. Based on a cognitive psychology perspective, cognitive variables (the individual's mediating system) are assumed to be critical factors determining both patient and physician behavior. The individual's psychological functioning is seen as a continuous reciprocal interaction between behavioral, cognitive, and environmental influences; i.e., an interactional paradigm is applied. The importance of research models including cognitive and situation variables to guide the search for appropriate research methods is stressed. An intensive research strategy with a small sample of respondents will often be necessary. Also, respondents should be asked to describe their reactions to specific medical situations. The drug information sender has to select a set of goals for disseminating information to patients. Among the goals most often selected are: message comprehension, receiver satisfaction, changes in knowledge, attitudes, and drug behavior, as well as health effects. More research is needed on how the patient's mediating system, the actual situation, and the perceived situation steer his search for the use of new drug information. A different set of factors influence the patient's decision to start a medicinal or drug treatment than the factors that influence his decision to continue a treatment. The latter factors include forgetfulness, misunderstandings, and the patient's interpretation of physiological signs. More cognitive-oriented research about drug compliance must be undertaken. In such studies the mediating systems of a group of patients could be considered before and after intervention. There are a great number of types of inappropriate (irrational) prescribing. However, a physician may prescribe rationally in one area but irrationally in another. Face-to-face education of physicians has been shown to be effective in reducing inappropriate prescribing in a number of studies. "Overprescribing" of benzodiazepine has been an issue of intensive professional debate during the last decades. The two groups who criticize and defend the existing use of benzodiazepines build their views on different assumptions about the interaction between mind and brain as well as making different value assumptions regarding the use of a psychotropic drug. There is a need for prescription studies where a cognitive and interactional perspective is combined with an information-processing and a normative perspective. The benzodiazepines dependency problem has provoked lively discussion among professionals and the general public. Long-term benzodiazepine use and personality disorders increase the risk of the patient becoming dependent. A great number of research models have been suggested for the analysis of prescription drug dependency and as guides to the treatment of dependency.(ABSTRACT TRUNCATED AT 400 WORDS)

Epidemiologic evaluation of drug use in children

To define and evaluate the attention devoted to drug use in children rather than just review existing reviews, the present attempt is to seek out the primary sources of information in the hope that this effort would not only yield more reliable data, but would also provide an opportunity for reconsidering methodological problems which are possibly even more important. An English-language literature search for drug use in children from 1988 was conducted on two databases and a manual search was made of the literature, with a check of references quoted in main original articles, reviews and textbooks. The review was then organized in two main sections: an overall evaluation of the recent literature concerning drug use in children; the epidemiological profile of drug exposure as described cumulatively by the drug-utilization studies. A substantial lack of systematic attention to this area of drug epidemiology was found: drug use in the children is a 'hidden' reality in the literature; the wealth of methodologic developments that have taken place in the general field of drug use monitoring has scantly reached children. Children can be considered still "methodologic orphans" with respect to the transferable knowledge on the benefit/risk profile of therapies they receive. A network has to be developed to monitor clinical problems, including drug use, as part of an "audit" of the overall management of children.

Challenge to clinical pharmacy practice in Malaysia

OBJECTIVE

To report on the current status and future trends of clinical pharmacy practice in Malaysia.

DATA SOURCES

Published conference reports and journal articles.

DATA EXTRACTION

Data on areas related to clinical pharmacy practice in Malaysian hospitals were gleaned from various publications.

DATA SYNTHESIS

Malaysia is capable of implementing clinical pharmacy services in hospitals and perhaps also in the community setting. The important factors in clinically oriented pharmacy practice include improvement of the drug-control process, development of physical and human resources, clinical pharmacy skills, and the training of practicing pharmacists. A number of Malaysian pharmacists have already developed a unit-dose drug distribution system, patient counseling, therapeutic drug monitoring, drug information, and total parenteral nutrition services.

CONCLUSIONS

The pharmacy profession in Malaysia has many challenges ahead and it is hoped that every practicing pharmacist will be highly committed to future professional needs so that clinical pharmacy practice in Malaysia becomes a reality.