Readability of patient information leaflets on over-the-counter (OTC) medicines

Readability of information imprinted in patient information leaflets (PILs) in Saudi Arabia: The case of antihypertensive medications

Background

The Saudi Food and Drug Authority (SFDA) requires marketing authorization holders to submit a PIL in both Arabic and English language. However, the readability of imprinted and disseminated Patient information leaflets (PILs) was not assessed extensively in Saudi Arabia. This study aims to assess the readability of PIL of antihypertensive drugs in both Arabic and English languages.

Method

This study was a descriptive quantitative analysis conducted in Saudi Arabia in August 2021. PILs of all oral antihypertensive medications in Saudi Arabia were included in the study. The Arabic and English PILs were extracted from the Saudi Drugs Information System (SDI) and pharmaceutical companies' registration documents. The study used Flesch-Kincaid grade level to assess the readability of English and sentence length to assess the Arabic texts. Descriptive analyses were used to assess the readability scores and the mean differences.

Results

It was found that almost 88% of English PILs were above recommended readability level compared to 79% of Arabic PILs. About 89% of English PILs of generic and 86% of brand-name medications were above the readability cutoff point compared with 83% of Arabic PILs of generic and 68% of brand-name medications. The means of grade level for readability of PILs for the widely used antihypertensive medications including angiotensin II receptor blockers (ARBs), antiadrenergic, diuretics, Beta-blockers (BBs), calcium channel blockers (CCBs), and combination antihypertensive medications, and CCBs were higher than the recommended readability level (p < 0.05). The highest mean grade level for readability among English PILs was for combinations of antihypertensive agents (9.35 ± 1.38, p 0.01) and among Arabic PILs was for ARBs (6.15 ± 1.62, p < 0.01).

Conclusions

The majority of PILs of antihypertensive medications were above the recommended readability level that can be understood by the majority of the public, especially among generic medications and the most widely used antihypertensive medications. The study findings highlight the need of implementing guidelines to improve the readability of information imprinted in PILs and adopt new regulations requiring readability assessment for manufactures before submitting the PILs to the SFDA.

Evaluation of Flour Safety Messages on Commercially Available Packages: An Eye-Tracking Study

Wheat flour and baking mix have been associated with foodborne outbreaks and recalls, yet many consumers are unaware of the repercussions of consuming raw flour products. The objective of this study was to evaluate the accessibility of flour safety messages on commercially available packages and to identify consumer barriers to processing these messages. Eye-tracking technology was used to track the eye movements of 47 participants to assess their time to fixation (TTF) on the flour safety messages on 10 commercial packages. Notifications that were longer than one sentence were considered “long” messages, while notifications that consisted of only one sentence were considered short (S1–S5 and L1–L5). Only two participants (4.3%) found messages on all 10 packages. Highly accessible messages did not result in a high preference of presentation among participants. Most of the participants (98%) found the message on the S4 package, which correlated with the lowest TTF of 7.08 s. However, only 15% of those who found the S4 message chose it as their preferred message. Many participants who were interviewed said that they preferred messages that identified the reasoning for the warnings. They also preferred the messages that were well separated from other content on the package. Flour safety messages on the current packages are not effective to convey information and change consumer behavior. More science-based messaging strategies need to be developed to provide guidance for flour safety communication.

Poor compliance documenting informed consent in trauma patients with distal radius fractures compared to elective total knee arthroplasty

Background

The purpose of this study was (1) to evaluate the adequacy of informed consent documentation in the trauma setting for distal radius fracture surgery compared with the elective setting for total knee arthroplasty (TKA) at a large public hospital and (2) to explore the relevant guidelines in New Zealand relating to consent documentation.

Methods

Consecutive adult patients (≥16 years) undergoing operations for distal radius fractures and elective TKA over a 12‐month period in a single‐centre were retrospectively identified. All medical records were reviewed for the risks and complications recorded. The consent form was analysed using the Flesch Reading Ease Score (FRES) and the Simple Measure of Gobbledygook (SMOG) index readability scores.

Results

A total of 133 patients undergoing 134 operations for 135 distal radius fractures and 239 patients undergoing 247 TKA were included. Specific risks of surgery were recorded significantly less frequently for distal radius fractures than TKA (43.3% versus 78.5%, P < 0.001). Significantly fewer risks were recorded in the trauma setting compared to the elective (2.35 ± 2.98 versus 4.95 ± 3.33, P < 0.001). The readability of the consent form was 40.5 using the FRES and 10.9 using the SMOG index, indicating a university undergraduate level of reading.

Conclusions

This study has shown poor compliance in documenting risks of surgery during the informed consent process in an acute trauma setting compared to elective arthroplasty. Institutions must prioritize improving documentation of informed consent for orthopaedic trauma patients to ensure a patient‐centred approach to healthcare.

Health literacy for children and families

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

The Information for the Dosing of Medicinal Products in Different Age Intervals Is Ambiguous

OBJECTIVES

Information on the use of medicinal products should be particularly clear and un-ambiguous, including the information on dosing for children. Age groups of children in patient information leaflets are sometimes described with a "gap" (eg, 2-4 years, 5-12 years) or without a gap (2-4 years, 4-12 years). The first style is based on the view that person's age is a discrete variable and the second style is based on continuous understanding of person's age. The aim of this 3-language study was to test if these 2 styles are comprehensive.

METHODS

We presented a dosing chapter from patient information leaflet to 274 volunteers and asked them what dose they would use for a child whose age is on the border between the two age intervals.

RESULTS

We found that all commonly used styles are ambiguous. On average, 10% to 20% of people understand the instructions differently than the majority.

CONCLUSIONS

A need exists to develop a new, unambiguous style to present this information and prevent suboptimal dosing of drug with a lack of efficacy or additional risks of adverse effects.

Informed consent in orthopaedics

Aims

Informed patient consent is a legal prerequisite endorsed by multiple regulatory institutions including the Royal College of Surgeons and the General Medical Council. It is also recommended that the provision of written information is available and may take the form of a Patient Information Leaflet (PIL) with multiple PILs available from leading orthopaedic institutions. PILs may empower the patient, improve compliance, and improve the patient experience. The national reading age in the United Kingdom is less than 12 years and therefore PILs should be written at a readability level not exceeding 12 years old. We aim to assess the readability of PILs currently provided by United Kingdom orthopaedic institutions.

Patients and Methods

The readability of PILs on 58 common conditions provided by seven leading orthopaedic associations in January 2017, including the British Orthopaedic Association, British Hip Society, and the British Association of Spinal Surgeons, was assessed. All text in each PIL was analyzed using readability scores including the Flesch–Kincaid Grade Level (FKGL) and the Simple Measure of Gobbledygook (SMOG) test.

Results

The mean FKGL was 10.4 (6.7 to 17.0), indicating a mean reading age of 15 years. The mean SMOG score was 12.8 (9.7 to 17.9) indicating a mean reading age of 17 years.

Conclusion

Orthopaedic-related PILs do not comply with the recommended reading age, with some requiring graduate-level reading ability. Patients do not have access to appropriate orthopaedic-related PILs. Current publicly available PILs require further review to promote patient education and informed consent. Cite this article: Bone Joint J 2018;100-B:1253–9.

Developing visual images for communicating information aboutantiretroviral side effects to a low-literate population

The side effects of antiretroviral (ARV) therapy are linked to altered quality of life and adherence. Poor adherence has also been associated with low health-literacy skills, with an uninformed patient more likely to make ARV-related decisions that compromise the efficacy of the treatment. Low literacy skills disempower patients in interactions with healthcare providers and preclude the use of existing written patient information materials, which are generally written at a high reading level. Visual images or pictograms used as a counselling tool or included in patient information leaflets have been shown to improve patients' knowledge, particularly in low-literate groups. The objective of this study was to design visuals or pictograms illustrating various ARV side effects and to evaluate them in a low-literate South African Xhosa population. Core images were generated either from a design workshop or from posed photos or images from textbooks. The research team worked closely with a graphic artist. Initial versions of the images were discussed and assessed in group discussions, and then modified and eventually evaluated quantitatively in individual interviews with 40 participants who each had a maximum of 10 years of schooling. The familiarity of the human body, its facial expressions, postures and actions contextualised the information and contributed to the participants' understanding. Visuals that were simple, had a clear central focus and reflected familiar body experiences (e.g. vomiting) were highly successful. The introduction of abstract elements (e.g. fever) and metaphorical images (e.g. nightmares) presented problems for interpretation, particularly to those with the lowest educational levels. We recommend that such visual images should be designed in collaboration with the target population and a graphic artist, taking cognisance of the audience's literacy skills and culture, and should employ a multistage iterative process of modification and evaluation.

Evaluating the application of research-based guidance to the design of an emergency preparedness leaflet

Guidelines for the design of emergency communications were derived from primary research and interrogation of the literature. The guidelines were used to re-design a nuclear emergency preparedness leaflet routinely distributed to households in the local area. Pre-test measures of memory for, and self-reported understanding of, nuclear safety information were collected. The findings revealed high levels of non-receipt of the leaflet, and among those who did receive it, memory for safety advice was poor. Subjective evaluations of the trial leaflet suggested that it was preferred and judged easier to understand than the original. Objective measures of memory for the two leaflets were also recorded, once after the study period, and again one week or four weeks later. Memory for the advice was better, at all time periods, when participants studied the trial leaflet. The findings showcase evaluation of emergency preparedness literature and suggest that extant research findings can be applied to the design of communications to improve memory and understandability.

STATEMENT OF RELEVANCE

Studies are described that showcase the use of research-based guidelines to design emergency communications and provide both subjective and objective data to support designing emergency communications in this way. In addition, the research evaluates the effectiveness of emergency preparedness leaflets that are routinely distributed to households. This work is of relevance to academics interested in risk communication and to practitioners involved in civil protection and emergency preparedness.

An illustrated leaflet containing antiretroviral information targeted for low-literate readers: development and evaluation

OBJECTIVE

To apply a dual visual/textual modal approach in developing and evaluating a medicine information leaflet with pictograms suitable for low-literate HIV/AIDS patients. To identify and recommend best practices in this type of information design.

METHODS

A simple leaflet incorporating pictograms was designed for an antiretroviral regimen. Cognitive testing for understanding was conducted in 39 low-literate, South African, antiretroviral-naïve adults. Participants were required to locate and explain the information, and were questioned on their opinion of leaflet layout and contents.

RESULTS

Average understanding of the leaflet was 60%. Basic medication information was the best understood. An overall lack of knowledge of HIV/AIDS and its core concepts was found. Only half the participants considered this simple leaflet "easy" to read. All endorsed the inclusion of pictograms.

CONCLUSION

This testing method used in ARV-naïve individuals was invaluable in identifying areas needing modification before its use in patients. Text associated with pictograms was more noticeable and better understood, but only if they were closely juxtaposed.

PRACTICE IMPLICATIONS

Leaflet design should consider culture and literacy skills, be informed by learning theory and design principles, include visuals to enhance appeal and improve understanding, and involve end-users. Verbal counseling should accompany written information.

Pictograms in pharmacy

This review examines the use of pictograms in health care. Well designed pictograms are simple, clear, graphic symbols able to convey their intended meaning to all patients, including those who are illiterate, elderly or visually impaired. Although some research on the effectiveness of pictograms has not supported the hypothesis that pictograms are beneficial for the acquisition and comprehension of information, most studies investigating health-related applications of pictograms have shown them to be of benefit in the comprehension and recall of instructions on prescription and over-the-counter medicines. However, the success of pictograms as a communication aid in pharmacy depends first on a rigorous design process, followed by well-designed, randomised, controlled trials using an appropriate method of evaluation. The final stage is to investigate the optimal way of using pictograms in practice and to assess their effect on behavioural outcomes, such as compliance. We discuss methodological issues associated with the design process of pictograms, the evaluation of pictograms in practice, reasons for their use in pharmacy and their potential in improving medication compliance. We also report on the positive and negative aspects of various pictograms that have been developed and tested in pharmacy.

Readability estimates for commonly used health-related quality of life surveys

PURPOSE

To estimate readability of seven commonly used health-related quality of life instruments: SF-36, HUI, EQ-5D, QWB-SA, HALex, Minnesota Living with Heart Failure Questionnaire (MLHFQ), and the NEI-VFQ-25.

METHODS

The Flesch-Kincaid (F-K) and Flesch Reading Ease (FRE) formulae were used to estimate readability for every item in each measure.

RESULTS

The percentage of items that require more than 5 years of formal schooling according to F-K was 50 for the EQ-5D, 53 for the SF-36, 80 for the VFQ-25, 85 for the QWB-SA, 100 for the HUI, HALex, and the MLHFQ. The percentage of items deemed harder than "easy" according to FRE was 50 for the SF-36, 67 for the EQ-5D, 79 for the QWB-SA, 80 for the VFQ-25, 100 for the HUI, HALex, and the MLHFQ.

CONCLUSIONS

All seven surveys have a substantial number of items with high readability levels that may not be appropriate for the general population.

Quality of medication information available on retail pharmacy Web sites

BACKGROUND

The Internet is becoming an important source for medication information. Although the quality of consumer medication information (CMI) in brick and mortar pharmacies has been reported to be suboptimal, little is known about the quality of CMI offered by pharmacy Web sites.

OBJECTIVE

To evaluate the quality, readability, and provision of Web functionality of 4 popular medications (atenolol, nitroglycerin, atorvastatin, and glyburide) available on the websites of 3 of the largest retail pharmacies: Walgreens, CVS Pharmacy, and Rite Aid.

METHODS

The quality of online medication information was evaluated by 2 reviewers using a preexisting evaluation instrument created by a national panel of experts. Readability level was assessed using the Gunning Fog Test. We also assessed the presence of 4 Web-specific functional criteria: (1) capability for font enlargement, (2) availability of a glossary of terms, (3) presence of an "Ask a pharmacist" feature, and (4) access to detailed medication information or full prescribing information.

RESULTS

Overall, medication information was 77% adherent to the criteria evaluated. When broken down by drug, CMI was most adherent for atorvastatin (83%), followed by glyburide (77%), atenolol (76%), and nitroglycerin (75%). The average readability level was found to be 10th grade. No pharmacy Web site provided the ability for font enlargement, a glossary of terms, or access to detailed medication information; however, all pharmacy Web sites provided an "Ask a pharmacist" service.

CONCLUSION

Although pharmacy Web sites were found to have an overall good content quality, the high readability level of text, areas of incomplete information, and limited use of desirable Web functionality suggest room for improvement.

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.

A systematic review of readability and comprehension instruments used for print and web-based cancer information

Adequate functional literacy skills positively influence individuals' ability to take control of their health. Print and Web-based cancer information is often written at difficult reading levels. This systematic review evaluates readability instruments (FRE, F-K, Fog, SMOG, Fry) used to assess print and Web-based cancer information and word recognition and comprehension tests (Cloze, REALM, TOFHLA, WRAT) that measure people's health literacy. Articles on readability and comprehension instruments explicitly used for cancer information were assembled by searching MEDLINE and Psyc INFO from 1993 to 2003. In all, 23 studies were included; 16 on readability, 6 on comprehension, and 1 on readability and comprehension. Of the readability investigations, 14 focused on print materials, and 2 assessed Internet information. Comprehension and word recognition measures were not applied to Web-based information. None of the formulas were designed to determine the effects of visuals or design factors that could influence readability and comprehension of cancer education information.

Assessment of prescribing information for generic drugs manufactured in the Middle East and marketed in Saudi Arabia

BACKGROUND

Little research has assessed the quality of manufacturer-provided prescribing information or documented differences in key aspects of drug information among different marketed generic products of the same drug, particularly in the Middle East and Arabian Gulf. We assessed the quality of written prescribing information for selected generic drugs marketed in Saudi Arabia and manufactured in various countries of the Middle East.

METHODS

We assessed the correctness and completeness of information pertaining to indications, dosage, cautions/contraindications, side effects and drug interactions in 37 package inserts for generic products registered in Saudi Arabia and manufactured in the Middle East, including atenolol (6 inserts), fluoxetine (4 inserts), ciprofloxacin (11 inserts), metformin (7 inserts), and omeprazole (9 inserts). We also described deficiencies in the quality and quantity of manufacturer-provided information that could be misleading to patients and prescribers.

RESULTS

We found substantial disagreement in information between generic package inserts versus the British National Formulary and the package insert of the brand product marketed in Saudi Arabia. A cumulative average of 63 +/- 16% of drug information indicators were in agreement with these standard references. Section headings with the least conformity with study references were those related to dosage (57 +/- 28%) and side effects (54 +/- 30%).

CONCLUSION

Our results indicate that national authorities should implement appropriate measures aimed at removing misleading and incorrect information in generic package inserts and incorporating crucial prescribing information that is missing. National authorities in the Middle East and Arabian Gulf should strengthen collaboration and information interchange among each other and with international agencies to maintain common quality standards for delivering information through package inserts.

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.

Readability of ocular medication inserts

OBJECTIVE

To determine the readability of ocular medication inserts and whether they are an appropriate source of medication information for patients.

MATERIALS AND METHODS

The Flesch-Kincaid and SMOG readability formulas were used to calculate the readability of 10 common glaucoma medication inserts (Alphagan, Azopt, Betoptic, Betimolol, Cosopt, Optipranolol, Rescula, Trusopt, Timoptic, and Xalatan) and 6 widely used nonglaucoma medication inserts (Alrex, Lotemax, Ocuflox, Patanol, Pred Forte, and Zaditor).

RESULTS

The 10 glaucoma medication inserts surveyed required an average overall grade level of 12.9 +/- 0.6 by the Flesch-Kincaid Index and of 13.5 +/- 0.6 by the SMOG formula. The 6 nonglaucoma medication inserts had an overall grade level of 11.1 +/- 0.6 by the Flesch-Kincaid Index and of 11.7 +/- 0.9 by the SMOG formula. All medications reviewed were above the eighth-grade level recommended by the Flesch-Kincaid Index for public materials.

CONCLUSIONS

Ocular medication inserts are too complex to be an adequate source of medication information for the average American adult. This study highlights the need for improving communication and education regarding patients' medications.

[Measurement of the legibility of written texts. Correlation between the Flesch manual method and computer methods]

OBJECTIVE

To compare, for the calculation of the Flesch legibility index, the original manual method and the computer programmes Word Perfect 7 and Microsoft Word 2000; and to correlate these with other computer measurements of legibility.

DESIGN

Descriptive, observation study.

SETTING

A Madrid Health Centre, within a study of the legibility of health education (HE) leaflets.

MATERIAL

A sample of text from 100 HE leaflets and 11 general control texts. Main measurements. The 11 texts were analysed through Flesch' s original manual method and the computer programmes mentioned, with which the number of words and sentences, the Flesch scores, the index of sentence complexity and the LEGIN index were calculated. Pearson's correlation coefficient was calculated for all the variables.

RESULTS

There was very good correlation between the manual measurement of the Flesch index, the number of words and sentences, and their determination by means of computers (r>0.75); and excellent correlation between the two programmes (r>0.9). The results support the cut-off scores in other studies for legibility measured by computer.

CONCLUSIONS

Measurement of legibility through the computer programmes used can reliably replace manual measurement of the Flesch index.

Does legally mandated consent to psychotherapy ensure ethical appropriateness?: the Colorado experience

We analyzed a sample of 356 forms containing information that Colorado law legally requires both licensed and unlicensed therapists to disclose to clients. The majority of forms contained the legally mandated information; fewer forms contained ethically desirable information. The average readability grade level was 15.74, corresponding to upper-level college, and 63.9% of the forms reached the highest (most difficult) readability grade of 17+. Therapists are obeying the law, but do not appear to be taking advantage of the opportunity to provide their clients useful information in an accessible way.

The evaluation of pharmaceutical pictograms in a low-literate South African population

An inability to read and understand written medication instructions may be a major contributory factor to non-compliance in certain patient populations, particularly in countries with a high illiteracy rate such as South Africa. Twenty three pictograms from the USP-DI and a corresponding set of 23 locally developed, culturally sensitive pictograms for conveying medication instructions were evaluated in 46 Xhosa respondents who had attended school for a maximum of 7 years. Respondents were tested for their interpretation of all 46 pictograms at the first interview and again 3 weeks later. The correct meaning of each pictogram was explained at the end of the first interview. Preference for either the Local or USP pictograms was determined. At the follow-up interview, 20 of the Local pictograms complied with the ANSI criterion of >/=85% comprehension, compared with 11 of the USP pictograms. Respondents indicated an overwhelming preference for the Local pictograms.

Review article: over-the-counter drugs and the gastrointestinal tract

An increasing number of drugs are becoming available over-the-counter, empowering patients to treat them- selves. Although drugs presently available over-the-counter are generally safe, there are issues of safety and possible delays in diagnosis of serious conditions. Therefore it is vital that patients are made aware of the indications and limitations of over-the-counter drugs through improved communication and education. Pharmacists and drug companies will have an increasingly important role in giving information and advice to patients. This review looks at the present and future of over-the-counter medication, highlighting the safety aspects.

Writing wrongs? An analysis of published discourses about the use of patient information leaflets

Much has been written about how to communicate with patients, but there has been little critical scrutiny of this literature. This paper presents an analysis of publications about the use of patient information leaflets. It suggests that two discourses can be distinguished in this literature. The first of these is the larger of the two. It reflects traditional biomedical concerns and it invokes a mechanistic model of communication in which patients are characterised as passive and open to manipulation in the interests of a biomedical agenda. The persistence of the biomedical model in this discourse is contrasted with the second discourse, which is smaller and more recent in origin. This second discourse draws on a political agenda of patient empowerment, and reflects this in its choice of outcomes of interest, its concern with the use of leaflets as a means of democratisation, and its orientation towards patients. It is suggested that the two discourses, though distinct, are not entirely discrete, and may begin to draw closer as they begin to draw on a wider set of resources, including sociological research and theory, to develop a rigorous theoretically grounded approach to patient information leaflets.

Quality of written information used in Down syndrome screening

A qualitative assessment was performed on 81 leaflets used in maternal serum Down syndrome screening from National Health Service (NHS) obstetric units and private screening services. Quality was assessed by factual content, presentation and reading ease and this was amalgamated into a single overall score expressed as a percentage of the maximum possible score. Eleven (14%) leaflets included all eight factual items recommended by the Royal College of Obstetricians and Gynaecologists (RCOG); only one included these and a further nine items recognised as important to the consumer. Three (4%) leaflets contained information that was incorrect and 17 (21%) that was misleading or inconsistent. Using published criteria six (7%) leaflets were well presented and ten (12%) were fairly easy to read. The average reading age was 13-14 years. The overall quality score showed that five leaflets had 80% or more of the total possible score. However a substantial number, 15 (19%), were totally unacceptable having scores of 40% or less. In general the quality of leaflets used in the UK is considered poor. A national peer-reviewed leaflet should be prepared which can be modified to suit local policy.

A rapid appraisal method for the selection and pre-testing of environmental health leaflets

This paper presents a rapid appraisal method for the selection and pre-testing of printed leaflets on environmental health issues. The method combines a staff questionnaire, a readability test and a target population survey and is designed to aid leaflet selection in a way which is practically feasible yet retaining an acceptable level of face validity. A multiple, embedded case study was used to field-test the method and the feedback from this is discussed. The results suggest that the method has the potential to replace ad hoc arrangements by the gatekeepers and make the selection of leaflets more a matter of structured decision-making involving representatives of all the stake-holders.

Providing patients with written medication information

OBJECTIVE

To review the literature and provide recommendations for the development and dissemination of written medication information to patients and their care providers.

DATA SOURCES

A MEDLINE search (1966-1997) of the English-language literature was performed to identify articles pertaining to the development or use of written medication information. A search of the Internet was conducted by using Yahoo as the guide and "medication information" as the search term. Additional resources were obtained through texts, bibliographies, and catalogs from medical publishers.

DATA EXTRACTION

Reports documenting the creation and use of written medication information systems were reviewed, as well as studies of readability and reading skills assessment. Examples of materials available for purchase by laypeople and healthcare providers were also examined.

DATA SYNTHESIS

Current statistics support the widespread availability of written medication information for patients and care providers. The goal set forth by the Food and Drug Administration of having 75% of patients receive written information by the year 2000 appears achievable. However, there are still many issues to address. Content is not standardized, and materials are frequently written at reading levels higher than that of the average patient. The development and use of resources requiring only minimal reading skills and an increase in the availability of materials written in Spanish are needed.

CONCLUSIONS

Written medication information provides a useful addition to counseling by healthcare professionals. A wide variety of prepared materials is available, as well as resources for those interested in developing tools for a specific patient, population, or setting. Healthcare professionals should be aware of the limitations of some resources. Content and readability must be appropriate for the intended audience for these tools to serve a useful role in patient education.

The comprehensibility of asthma education materials

Asthma information pamphlets, brochures and other media materials are produced by a range of organisations for a diverse range of educational purposes. It is important to understand the principles of preparing appropriate and intelligible written material, to increase the probability that they will be more likely to improve health outcomes. Asthma patient education material, like many other types of health education material, is often written at a reading age above the target audience, and is less likely to be comprehended. Attention should be paid to the principles of good written communication in the preparation of such material. Such material should ideally be used in conjunction with verbal advice, as part of a medical consultation or asthma education program. Other asthma education media, including public education and mass communications material, should be subject to formative evaluation to assess its suitability and relevance for the proposed target audience.

Comparative evaluation of patient information leaflets by pharmacists, doctors and the general public

This study was undertaken to compare and contrast the views of pharmacists, general practitioners (GPs) and the general public on the value or otherwise of pharmacy-generated patient information leaflets. All three groups perceived these leaflets to be useful and an aid to improving compliance. Concerning the information included in leaflets, GPs rated the inclusion of a section on side-effects as being the least important, whilst pharmacists and the general public rated information on the storage of medicines as being least important. Pharmacists' estimates on what percentage of patients actually read leaflets were significantly lower than estimates by the general public. General practitioners and pharmacists generally concurred on the types of patients for whom leaflets are considered unsuitable, although a significantly higher percentage of pharmacists than GPs identified unsuitable patients. There were reservations by the pharmacists concerning the cost-effectiveness of leaflet facilities and on the value of leaflets compared with verbal counselling. The general public expressed the view that a leaflet facility would affect their choice of pharmacy and that they would be prepared to wait an additional short time to receive such a leaflet. Almost all GPs thought that it was in the patient's best interest to receive an information leaflet.

Emergency medicine research consent form readability assessment

STUDY OBJECTIVE

To determine the level of education necessary to understand informed consent documents used to enroll subjects in emergency medicine research.

METHODS

The directors of 96 accredited emergency medicine residency programs were asked to provide copies of research consent forms approved for patient enrollment at their facilities. A computer program was used to evaluate the readability of the documents submitted. The consent forms were stratified by degree of risk to the subject and compared with the use of ANOVA and the Kruskal-Wallis test.

RESULTS

Ninety-four informed consent documents were received from 45 program directors. After exclusion of 6 forms, 88 were analyzed using the software program RightWriter 5.0. The mean readability index (years of education needed to understand the content) was 10. The length and complexity of the consent forms increased as risk to the subject increased (P = .03).

CONCLUSION

Informed consent documents used in emergency medicine research may be too complex for the average patient to understand. A positive correlation exists between protocol risk and consent from complexity.

Prescribed medication and nutrition of social care patients in Crete, Greece

OBJECTIVE

The aim of this study was to make a systematic registration of a group of 354 social care indigent patients in relation to: their pharmaceutical needs: the conditions for which it was prescribed, its cost, and details of prescriptions. In addition patients' eating patterns relating to and knowledge of how to use their medication was assessed. They were compared to a control group of 153 Social Security patients.

SUBJECTS

The Social Care indigent patients were of low income, consisting of groups as unmarried mothers with their children and Greeks emigrants coming back home from other countries (Albania, Russia, Georgia, Ukraine, Romania etc.). The socio-demographic profiles of this group reveal an unemployment rate of 74% and an illiteracy rate of 18%. As regards marital status, 20% are bachelors and 12% divorcees.

RESULTS

The results of the study indicated no significant difference between the two groups in the mean cost of prescription (40 ECU for Social Care patients vs 32 ECU for Social Security patients), in the mean number of medication per prescription (2.6 vs 2.6 respectively), in the percentages of the Daily Defined Doses and the cost of the various categories of drugs. For both groups, the most common drugs were those of the Cardiovascular system (30% vs 26%), Gastrointestinal system (17% vs 27%) and Nervous system (16% vs 18%). The most common diagnosis was Hypertension (10% vs 8%) and the most common drugs were Ranitidine (3% vs 2%), Diclofenac (3% vs 3%), Salbutamol (3% vs 3%) and Paracetamol (2% vs 2%). Significant differences between Social Care patients to Social Security patients respectively were found regarding: knowing how to take their medication correctly (47% vs 77%), knowing for how long treatment needed to be taken (21% vs 43%), requesting information from the pharmacist (39% vs 68%) knowledge of dietary instructions regarding medication (17% vs 41%) and in smoking more than 20 cigarettes per day (15% vs 3%).

CONCLUSIONS

The results indicated that the Social Care patients, in comparison with the patients of the Social Security, need more education and more help in the area of the proper use of drugs and in the personal contact that this procedure involves.

Patients, society, and the increase in self medication

Self medication with over the counter medicines has long been a feature of the lay health system. With the reclassification of certain drugs, the public can buy preparations that were previously available only prescription. Sales of over the counter medicines are now equivalent to a third of the NHS drugs bill; governments throughout the world see self medication as a way of shifting some of the cost of health care onto consumers. The trend towards increased self care and with it the increasing empowerment of patients has many potential benefits; collaboration between doctors and pharmacists will be critical.

Patient information leaflets on over-the-counter (OTC) medicines: the manufacturer's perspective

A survey was undertaken to assess the views of the manufacturers of over-the-counter (OTC) products about (i) the value of patient information leaflets (PILs), (ii) the recent European Community directive relating to PILs and (iii) the procedures which are in place for producing and testing PILs. Although approximately half (15/31) of the respondents (response rate 31/58) thought that PILs were more important for OTC than prescription only medicines, this view was not unanimous. A majority (18/28) thought that the new EC directive would provide too much information to patients although only a small number (2/27) thought that the regulations were unnecessary. Indication for the product was thought to be the most important information for the immediate outer packaging. Only about one-third (35%) of patients are thought to read PILs, in contrast to the majority who read the outer packaging. A wide variety of departments contribute to preparing PILs. The marketing department had a major input particularly with respect to layout and testing of leaflets. On the whole the design and production of PILs involves considerable effort but their testing appears less structured and thorough.