Readability of commercial and generic contraceptive instructions

Medication Safety: Effect of Content and Format of Prescription Drug Labels on Readability, Understanding, and Medication Use: A Systematic Review

Objective:

To evaluate the evidence regarding the optimal content and format of prescription labels that might improve readability, understanding, and medication use.

Data Sources:

We performed a systematic review of randomized controlled trials, observational studies, and systematic reviews from MEDLINE and the Cochrane Database (1990–June 2005), supplemented by reference mining and reference lists from a technical expert panel.

Study Selection:

We selected studies that focused on the content of physician–patient communication about medications and the content and format of prescription drug iabels.

Data Extraction:

Two reviewers extracted and synthesized information about study design, populations, and outcomes,

Data Synthesis:

Of 2009 articles screened, 36 that addressed the content of physician–patient communication about medications and 69 that were related to the content or format of medication labels met review criteria. Findings showed that patients request information about a drug's indication, expected benefits, duration of therapy, and a thorough list of potential adverse effects. The evidence about label format supports the use of larger fonts, lists, headers, and white space, using simple language and logical organization to improve readability and comprehension. Evidence was not sufficient to support the use of pictographic icons. Little evidence linked label design or content to measurable health outcomes, adherence, or safety.

Conclusions:

Evidence suggests that specific content and format of prescription drug labels facilitate communication with and comprehension by patients. Efforts to improve the labels should be guided by such evidence, although additional study assessing the influence of label design on medication-taking behavior and health outcomes is needed. Several policy options exist to require minimal standards to optimize medical therapy, particularly in light of the new Medicare prescription drug benefit.

Health literacy and contraception: A readability evaluation of contraceptive instructions for condoms, spermicides and emergency contraception in the USA

OBJECTIVE

To assess readability of over-the-counter (OTC) contraceptive product instructions currently available, compare the results with previous studies from a decade ago, and review the implications for health care providers, in particular pharmacists counseling on OTC contraceptives.

METHODS

A sample of contraceptive instructions was submitted to a readability analysis using four standard readability formulas. Products included condoms, spermicides, and emergency contraception instruction pamphlets.

RESULTS

Reading grade levels for condoms ranged from 6th to 12th grade. The average reading levels for the spermicides were 9th-10th grade and for the emergency contraceptives 10th-12th grade. These results were consistent with those of similar studies performed a decade ago.

CONCLUSIONS

Consumers need to have at least a high school reading level in order to comprehend current product instructions. Very little has changed in the past decade regarding readability of OTC contraceptive patient instructions, despite calls to simplify written instructions. Healthcare providers, in particular pharmacists, must be aware of these disparities to enhance patient education and advocate for simpler reading materials.

Written information about individual medicines for consumers

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

To err is human: patient misinterpretations of prescription drug label instructions

OBJECTIVE

To examine the nature and cause of patients' misunderstanding common dosage instructions on prescription drug container labels.

METHODS

In-person cognitive interviews including a literacy assessment were conducted among 395 patients at one of three primary care clinics in Shreveport, Louisiana, Jackson, Michigan and Chicago, Illinois. Patients were asked to read and demonstrate understanding of dosage instructions for five common prescription medications. Correct understanding was determined by a panel of blinded physician raters reviewing patient verbatim responses. Qualitative methods were employed to code incorrect responses and generate themes regarding causes for misunderstanding.

RESULTS

Rates of misunderstanding for the five dosage instructions ranged from 8 to 33%. Patients with low literacy had higher rates of misunderstanding compared to those with marginal or adequate literacy (63% versus 51% versus 38%, p<0.001). The 374 (19%) incorrect responses were qualitatively reviewed. Six themes were derived to describe the common causes for misunderstanding: label language, complexity of instructions, implicit versus explicit dosage intervals, presence of distractors, label familiarity, and attentiveness to label instructions.

CONCLUSION

Misunderstanding dosage instructions on prescription drug labels is common. While limited literacy is associated with misunderstanding, the instructions themselves are awkwardly phrased, vague, and unnecessarily difficult.

PRACTICE IMPLICATIONS

Prescription drug labels should use explicit dosing intervals, clear and simple language, within a patient-friendly label format. Health literacy and cognitive factors research should be consulted.

The Impact of Medical Terminology on Readability of Patient Education Materials

Most health-related literature is written above the reading ability of the lay audience; however, no studies to date have identified the impact of medical terms on readability of health education materials. The purpose of this study was to identify whether there was a change in calculated reading levels of patient education brochures after medical terms were removed from analysis passages. The reading levels of 5 patient education brochures were analyzed before and after removal of medical terms, using both the Fry and Simple Measure of Gobbledegook (SMOG) readability formulas. Results indicated that the reading levels for all brochures were significantly lower after removal of medical terminology, but they remained above the 5th to 6h grade level recommended by health education experts. Findings hold implications for healthcare professionals in relation to the development and evaluation of patient education materials.

Relationships among educational material readability, client literacy, perceived beneficence, and perceived quality

Illiteracy remains a pervasive problem that compromises quality health care, limits understanding of health information, and potentially leads to poor health outcomes. This study demonstrated that participants' measured reading level was significantly lower than both their stated years of education and readability of an educational pamphlet. A positive relationship was identified between measured reading level and pamphlet helpfulness (client-perceived beneficence). Participants perceived care quality as good to very good. Quality client education requires use of either educational materials appropriate for the measured reading level of clients or alternatives to written material.

Easy-to-read consumer communications: a missing link in Medicaid managed care

Effective consumer communication is key to successfully moving Medicaid recipients into managed care systems and realizing the promised cost savings from the upheaval. Yet, little attention has been paid to educating these consumers with easy-to-read materials. The Maine Area Health Education Center (AHEC) Health Literacy Center, with the support of the Center for Health Care Strategies, Inc., addressed the problem by offering three national skills training workshops called Writing for the Medicaid Market. The training was marketed to public and private organizations providing Medicaid managed care services, including state Medicaid officials, health benefit counselor staff (enrollment brokers), managed care plan (HMO) staff, and consumer advocates. The training addressed the core issue in health literacy: the mismatch between the low literacy skills of the target population and the high reading level of most health and managed care materials. Posttraining survey data revealed that training was successful in skill building, but also that it addressed only the tip of the iceberg. Faulty and/or nonexistent communication planning limits the success not only of Medicaid, but of other large health and social programs as well. The authors outline the broad scope of the national health literacy problem, share their posttraining survey data, discuss lessons extrapolated from both their data and their experience, and propose a national agenda to address a vast and generally ignored public problem.

The illiterate patient: screening and management

Illiteracy, which affects about 22% of adults in the United States, can hamper patient communication, treatment, compliance, and access to care. Alternative communication methods and active screening for illiteracy are crucial to addressing this problem.

Readability of advance directive documents

PURPOSE

To assess the readability of advance directive documents.

DESIGN

Descriptive.

SAMPLE

Convenience, 10 advance directive documents from various sources.

METHODS

Advance directive documents were electronically scanned in 1994 then evaluated using three readability formulas: Flesch-Kincaid Grade Level, Flesch Reading Score, and Gunning's Fog Index.

FINDINGS

The average readability (in school grade levels) of the 10 documents was 11.3 using the Flesch-Kincaid Grade Level and 18.2 using the Gunning's Fog Index.

CONCLUSIONS

All documents were above reading levels usually recommended for patients.

CLINICAL IMPLICATIONS

Patients must be able to read and understand advance directive documents before signing them. Refinement of the documents is recommended to support patient understanding and autonomy in end-of-life care.

Patient education materials nurses use in community health

This study examined the reading level of patient education materials commonly used by nurses in a local health department, a community health center, and a home health care agency, and it also examined the cultural and ethnically related information included in the content of the selected educational materials. Results showed that a ninth-grade reading level was required for these patient education materials. A commercially developed booklet on parenting skills for teenage parents required the lowest reading level (fifth grade). In contrast, graduate reading level was required for materials dealing with the patient's bill of rights. Culturally sensitive information was found in only 4 of the 47 materials. In the clinical settings in which these materials were used, more than 90 ethnic and cultural groups were served. The materials used to educate these groups failed to recognize cultural beliefs, values, languages, perceptions, and attitudes held by patients and families.

Emergency department discharge instructions and patient literacy: a problem of disparity

This two-part study was designed to determine the reading level necessary to understand commonly used emergency department (ED) discharge instructions and the functioning reading level of adult patients treated in an urban hospital ED. In the first phase, 10 preprinted patient discharge instructions were analyzed using the Flesch Reading Ease Score. The average reading level required to comprehend these instructions was 9.8, with a range from the 8th to the 14th grade. In the second phase of the study, a reading exam, based on the Stanford Diagnostic Reading Test, was administered to 82 ED patients prospectively. The mean reading level was 9.8, with a median level of 10; approximately 45% of the ED patients would be unable to understand the preprinted discharge instructions. ED discharge instructions are frequently written at a level beyond the comprehension of a significant portion of the population.

Educating patients with limited literacy skills: the effectiveness of printed and videotaped materials about colon cancer

We investigated whether printed or videotaped information is more effective in enhancing colon cancer knowledge. Subjects (n = 1100) were randomized into three groups: to receive a booklet, view a videotape, or receive no intervention. Subjects receiving the intervention showed increased knowledge compared with control subjects (booklet = 23% and videotape = 26% vs no intervention = 3%). Findings suggest that personalized educational materials are effective in enhancing colon cancer knowledge.

Functional illiteracy among emergency department patients: a preliminary study

STUDY OBJECTIVES

To determine the ability of emergency department patients to understand common written discharge instructions and the level of reading difficulty of standard discharge instructions.

DESIGN

The study was performed in two parts. In part 1, subjects were asked to read one set of standard written discharge instructions. Then, with the instructions to refer to, subjects were asked to answer five questions about the instructions. A subject's level of success was correlated with age, sex, and highest level of education. In part 2, 47 sets of standard written discharge instructions from six different EDs were computer analyzed using five commonly used readability formulas. Results were reported as grade levels.

SETTING

The ED of a large inner-city university hospital.

TYPE OF PARTICIPANTS

The subjects for part 1 were 400 adult ED patients who presented on randomly selected days.

MEASUREMENTS AND MAIN RESULTS

Part 1: A significant proportion of patients failed to answer correctly at least four of five questions. Patients educated beyond high school demonstrated higher levels of success than did those with less education. A trend was noted for younger subjects to perform better than older subjects. The answers to the three most frequently missed questions were contained within areas of difficult sentence structure or long paragraphs containing large amounts of information. Part 2: The average grade level required to understand instruction sheets ranged from 6.0 to 13.4. More difficult instruction sheets tended to contain numerous multi-syllabic words, long sentences, and difficult sentence structure.

CONCLUSION

A significant proportion of ED patients have a demonstrable inability to understand common written instructions. ED instruction sheets are written at a level of difficulty that is out of the readable range for many patients. Health care providers should strive to simplify written materials and to develop new methods for instructing those for whom current written materials have no meaning.