Patient Characteristics Influencing Evaluation of Written Medicine Information: Lessons for Patient Education

Effectiveness of a hospital-based education programme in improving knowledge of the use of nonsteroidal anti-inflammatory drugs among heart failure patients in a Malaysia regional hospital

Objectives

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) in heart failure patients is known to be associated with a wide range of adverse events, including an increased risk of cardiovascular complications. This study aimed to evaluate the effectiveness of an education programme in improving the knowledge about the safety of NSAID use among the hospitalized heart failure patients.

Method

This was a single-arm, quasi-experimental study. It was undertaken in a regional referral centre in Perak State, Malaysia. Each recruited patient received an educational leaflet and a 10-min counselling intervention by a clinical pharmacist. A 5-item questionnaire was used to assess their knowledge before and after the intervention. Each correct answer was awarded with 1 point, and a patient with a total score of 3 points or above was considered having adequate knowledge.

Key findings

A total of 31 patients received the intervention and completed the assessment. They were mainly female (61%), with a median age of 68 (interquartile range (IQR) = 22) years. Of all the patients, four (13.3%) reported a long-term use of NSAIDs, while only one (3.2%) reported the use of NSAIDs in 1 week before the hospitalization. The postintervention score (median = 3; IQR = 2) was shown to be significantly higher than the preintervention score (median = 1; IQR = 2; P = < 0.001). Additionally, the majority of the patients (86.7%) found the education programme was useful to avoid unnecessary NSAID use in the future.

Conclusions

Our findings suggest that the pharmacist-initiated education programme is useful and could be used as a long-term strategy to improve the knowledge about the safety of NSAID use in heart failure patients.

Attitudes towards sales and use of over-the-counter drugs in Sweden in a reregulated pharmacy market: a population-based study

OBJECTIVES

To analyse attitudes towards sales and use of over-the-counter (OTC) drugs in the Swedish adult population.

METHODS

Data were collected through the web-based Citizen Panel comprising 21 000 Swedes. A stratified sample of 4058 participants was emailed a survey invitation. Questions concerned use of OTC drugs, and attitudes towards sales and use of OTC drugs. Correlations between the attitudinal statements were assessed using Spearman's rank correlation. Associations between attitudes and participant characteristics were analysed using multinomial logistic regression.

KEY FINDINGS

Participation rate was 64%. Altogether 87% reported use of OTC drugs in the last 6 months. Approximately 10% of participants stated that they used OTC drugs at the first sign of illness, and 9% stated that they used more OTC drugs compared with previously, due to increased availability. The statement on use of OTC drugs at first sign of illness correlated with the statement about using more OTC drugs with increased availability. Socio-demographic factors (age, sex and education) and frequent use of OTC drugs were associated with attitudes to sales and use of OTC drugs.

CONCLUSIONS

Increased use due to greater availability, in combination with OTC drug use at first sign of illness illustrates the need for continuous education of the population about self-care with OTC drugs. Increased awareness of the incautious views on OTC drugs in part of the population is important. Swedish policy-makers may use such knowledge in their continuous evaluation of the 2009 pharmacy reform to review the impact of sales of OTC drugs in retail outlets on patient safety and public health. Pharmacy and healthcare staff could be more proactive in asking customers and patients about their use of OTC drugs and offering them advice.

Exploring consumer opinions on the presentation of side-effects information in Australian Consumer Medicine Information leaflets

Background

Consumer Medicine Information (CMI) is a brand‐specific and standardized source of written medicine information available in Australia for all prescription medicines. Side‐effect information is poorly presented in CMI and may not adequately address consumer information needs.

Objective

To explore consumer opinions on (i) the presentation of side‐effect information in existing Australian CMI leaflets and alternative study‐designed CMIs and (ii) side‐effect risk information and its impact on treatment decision making.

Design

Fuzzy trace, affect heuristic, frequency hypothesis and cognitive‐experiential theories were applied when revising existing CMI side‐effects sections. Together with good information design, functional linguistics and medicine information expertise, alternative ramipril and clopidogrel CMI versions were proposed. Focus groups were then conducted to address the study objectives.

Participants and setting

Three focus groups (n = 18) were conducted in Sydney, Australia. Mean consumer age was 58 years (range 50–65 years), with equal number of males and females.

Results

All consumers preferred the alternative CMIs developed as part of the study, with unequivocal preference for the side‐effects presented in a simple tabular format, as it allowed quick and easy access to information. Consumer misunderstandings reflected literacy and numeracy issues inherent in consumer risk appraisal. Many preferred no numerical information and a large proportion preferred natural frequencies.

Conclusions

One single method of risk presentation in CMI is unable to cater for all consumers. Consumer misunderstandings are indicative of possible health literacy and numeracy factors that influence consumer risk appraisal, which should be explored further.

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.

Pain Management in the Elderly: An FDA Safe Use Initiative Expert Panel's View on Preventable Harm Associated with NSAID Therapy

Optimization of current pain management strategies is necessary in order to reduce medication risks. Promoting patient and healthcare provider education on pain and pain medications is an essential step in reducing inadequate prescribing behaviors and adverse events. In an effort to raise awareness on medication safety, the FDA has launched the Safe Use Initiative program. The program seeks to identify areas with the greatest amount of preventable harm and help promote new methods and practices to reduce medication risks. Since the establishment of the program, FDA's Safe Use initiative staff convened a panel of key opinion leaders throughout the medical community to address pain management in older adults (≥65 years of age). The aim of the expert panel was to focus on areas where significant risk occurs and where potential interventions will be feasible, implementable, and lead to substantial impact. The panel suggested one focus could be the use of NSAIDs for pain management in the elderly.

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.

Communicating non-steroidal anti-inflammatory drug risks: verbal counseling, written medicine information, and patients' risk awareness

OBJECTIVE

To assess potential associations among physician counseling, pharmacist counseling, written medicine information (WMI) and patient awareness of non-steroidal anti-inflammatory drug (NSAID) risks.

METHODS

Three-hundred and eighty-two older, white and African American patients prescribed NSAIDs were surveyed regarding their NSAID risk awareness defined as an index score ranging from zero to four correctly identified risks (i.e., gastrointestinal bleeding, heart attack, hypertension, and kidney disease). Associations among NSAID risk awareness and patient-reported physician counseling, pharmacist counseling, and reading of WMI were evaluated in multivariable ordered logistic regression models and confirmed using path analysis.

RESULTS

Physician counseling was positively associated with reading WMI (p<0.001) and NSAID risk awareness (p<0.001). Pharmacist counseling was not associated with reading WMI (p=0.622) and neither pharmacist counseling (p=0.366) nor reading WMI (p=0.916) was associated with NSAID risk awareness.

CONCLUSIONS

Physicians play a prominent role in facilitating NSAID risk awareness whereas pharmacist counseling and WMI may have limited impact.

PRACTICE IMPLICATIONS

The lack of significant associations among pharmacist counseling and reading WMI with NSAID risk awareness suggests a missed opportunity to improve patient understanding. There is a need for coordinated and effective strategies to communicate risk information among physicians and pharmacists and to better integrate WMI into this process.

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.

Using single-item health literacy screening questions to identify patients who read written nonsteroidal anti-inflammatory medicine information provided at pharmacies

Our goal was to assess the relationships between single-item health literacy screening questions and reading prescription nonsteroidal anti-inflammatory drug (NSAID) written medicine information (WMI) provided at pharmacies. The health literacy of 382 patients from primary care physician practices in Alabama was estimated using validated health literacy screening questions related to understanding written medical information (SQ1); confidence in completing medical forms alone (SQ2); and need for assistance in reading hospital materials (SQ3). Reading WMI was measured by a "Yes" response to the question, "Often the drug store gives you written information such as pamphlets or handouts along with your prescription. Have you read about the risks of NSAIDs in this written material provided by the drug store?" Relationships were assessed using generalized linear latent and mixed models. Two-thirds (67.6%) of patients read WMI. Higher estimated health literacy was associated with increased odds of reading WMI. Adjusted odds ratios (95% CI) were 2.08 (1.08-4.03); 2.09 (1.12-3.91); and 1.98 (1.04-3.77) using SQ1-SQ3. Current WMI may be unable to meet the needs of those with inadequate health literacy. Health literacy screening questions can be used to triage patients at risk for not reading WMI so they can be assisted with supplemental educational strategies.

Rheumatological medicine literacy among Middle Eastern populations

BACKGROUND

It has been observed for years that many Middle Eastern patients with autoimmune rheumatic disorders, are more likely to be delayed in seeing a rheumatologist for their symptoms and that the rheumatology services are in general under-utilized by the population.

AIM

To explore if patients with autoimmune rheumatic disorders were truly delayed in seeing rheumatologists and to explore the possible reasons for that delay should any delay be documented.

SUBJECTS AND METHODS

Patients suffering from chronic autoimmune rheumatic disorders were interviewed and were asked to answer a questionnaire that assesses their initial set of actions when they had their first symptoms of disease, how much time they took to see a rheumatologist and their background knowledge about rheumatology as a specialty before and after they saw a rheumatologist.

RESULTS

Seventy-eight patients, 57 (73%) females and 21 (27%) males were included in this study. Their ages ranged from 11 to 72 years with a mean of 38.9 +/- 13 years. Patients' explanations for their initial symptoms were 'evil eye doing', disease, exertion, cold weather and trauma in 44%, 37%, 20%, 16% and 8% respectively. Ninety-six percent of patients had to make a total of 166 consultations first at other specialties before they were finally advised or directed to see a rheumatologist. Non-rheumatologist referrals to rheumatologists happened in only 33% of the time. The duration from the onset of the disease until patients finally came to see a rheumatologist ranged from 0.5 weeks to 432 weeks with a mean of 51 +/- 88 weeks.

CONCLUSIONS

General health literacy and knowledge of the rheumatology scope of service is extremely limited among Middle Eastern patients. Most patients with autoimmune rheumatic diseases make their initial consultations at clinics other than rheumatology clinics and non-rheumatologists have been shown to consistently not refer patients with rheumatic diseases to rheumatologists. Wrong diagnosis is attributed to rheumatology symptoms by non-rheumatologists 82% of the time. Level of education of patients, has no impact on their choice of the right specialty to be consulted for their disease symptoms.

Patient assessment of medication information leaflets and validation of the Evaluative Linguistic Framework (ELF)

OBJECTIVE

To obtain patient feedback about the structure and quality of medication information leaflets and validate the usefulness of the Evaluative Linguistic Framework (ELF) for improving written communication with patients.

METHODS

Triangulated feedback about a set of rheumatoid arthritis (RA) medication leaflets, some developed with knowledge of the ELF, was obtained from 27 people with RA from interviews, focus group discussion and self-administered questionnaires. The principal elements of the framework were investigated: overall generic structure and functions of each stage, interpersonal relationship between writer and reader, technicality of language and density of information.

RESULTS

Participant assessments of the leaflets aligned with the framework in terms of what constituted a good leaflet. While the main purpose of the leaflets was identified as being information provision, participants also wanted clear instructions, benefits to be highlighted and side effects to be comprehensively listed. For comprehensiveness and user-friendliness, leaflets developed with guidance of the ELF were consistently preferred.

CONCLUSION

According to people with RA, leaflets generated from a linguistic framework are clearer and more effective in communicating information about medications.

PRACTICE IMPLICATIONS

The ELF is a user-friendly, structured analytic system that can assist with the development of effective high quality patient information materials.

Sources of medicine information in Finland

OBJECTIVES

To identify differences in reported sources of medicine information between age groups and genders in one European country (Finland).

METHODS

A questionnaire on health behaviour was sent by mail to a random sample of 5000 Finns aged 15-64 years in the spring of 2005. The respondents (n=3287) were asked to report the sources from which they had received information about their medicines (both prescription medicines and self-medication) used over the past year (12 months). Number of respondents who had used medicines during the past year and reported at least one source of medicine information was 2348.

RESULTS

Women used PILs, newspapers, magazines, books, Health Food Stores (p<0.001) and advertisements (p<0.01) more than men as their medicine information sources. The oldest (50-64-year-olds) men and women reported doctors as sources of medicine information more commonly (p<0.001) and the Internet less commonly (p<0.001) than respondents in other age groups. The 15-29-year-old women received more information from PILs, nurses, relatives and friends (p<0.001) and from radio and television (p<0.05) than women in other age groups. The 15-29-year-old men found more information from relatives, friends, radio and television (p<0.001) than men in other age groups.

CONCLUSIONS

There are differences in the reported sources of medicine information between genders and age groups. Older persons seem mostly to use health professionals as their source, while younger persons seem to prefer the Internet or other sources which they can use by themselves. Women seem to be more active than men in searching for medicine information and, like younger persons, on their own initiative.

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

BACKGROUND

The Consumer Information Rating Form (CIRF) was developed as a direct method for measuring consumers' perceptions of the comprehensibility, utility, and design quality of written medicine information. The validity and reliability of the CIRF were evaluated in a small convenience consumer sample in the US. Its validity and reliability have yet to be established in a larger sample of consumers who are on chronic therapy in different settings.

OBJECTIVE

To determine the validity and reliability of the CIRF in Australian consumers on chronic therapy.

METHODS

Consumers read and subsequently evaluated a Consumer Medicine Information (CMI) leaflet for one of their own medications, using an adapted version of the CIRF. The construct validity and internal reliability of the adapted version of the CIRF were tested using principal components analysis (PCA) and Cronbach's alpha, respectively.

RESULTS

The adapted CIRF was completed by 282 consumers (aged 19-90 y; median 66; interquartile range 53-75 y; 60.3% females). Most respondents spoke primarily English at home (85.5%), had attained at least secondary education (84%), and had adequate health literacy levels (88.2%). Consumers rated CMI easy to read, understand, and navigate, but less easy to remember and keep. Most also found it to be useful and to contain the right amount of information. The design aspects also scored favorably, although CMI did score relatively poorly in terms of its attractiveness and tone (whether alarming or not). PCA yielded 3 factors (explaining 59.3% of the total variance) identical to those in the original CIRF: comprehensibility, utility, and design quality. All factors demonstrated good reliability (Cronbach's alpha 0.74, 0.92, and 0.75, respectively).

CONCLUSIONS

The CIRF appears to be a robust instrument for assessing consumers' perceptions of written medicine information. However, validity always needs to be reestablished when using a previously validated measure in a different population.

Project MED: effects of a Medication EDucation booklet series for individuals with intellectual disabilities

We developed eight heavily illustrated booklets covering patients' rights and responsibilities, antiepileptic medicines, and most psychotropic medicines. The language level was very basic but covered a wide range of information. We distributed free copies of the booklets, together with standardized questionnaires, to consumers with and without intellectual disabilities or other developmental disabilities; 604 questionnaires were returned. The majority of consumers indicated that they read the booklets, learned more about their rights/responsibilities and the medicines described, and found the booklets helpful. Consumers with intellectual disability experienced more difficulty than "average" consumers in understanding the materials, but satisfaction and understanding were reportedly high overall. Female and minority respondents indicated somewhat higher satisfaction with the booklets than did their counterparts.

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.

Enhancing patient education about medicines: factors influencing reading and seeking of written medicine information

OBJECTIVE

To investigate the influence of patient factors on patients' reading and seeking of written medicine information (WMI).

DESIGN

A cross-sectional questionnaire study. Main variables studied Patient's health locus of control, coping style, health literacy, demographics and disease state (independent variables) and patient's interest and likelihood in reading and seeking WMI (dependent variables).

MAIN OUTCOME MEASURES

Patient factors predicting interest in reading and seeking WMI.

SETTING AND PARTICIPANTS

Patients (total n = 479) from three Rheumatology/Pain clinics in teaching hospitals (n = 217) and 40 community pharmacies (n = 262) in metropolitan Sydney, Australia.

RESULTS

The majority of patients were interested and likely to read WMI about their prescription medicines. However, not many were likely to seek WMI and not many frequently sought WMI. Using logistic regression, patients' interest in reading WMI was predicted by their coping style [monitor vs. blunter, odds ratio (OR) = 2.19, confidence interval (CI) = 1.17-4.10], health literacy levels (adequate vs. inadequate/marginal, OR = 2.86, CI = 1.16-7.05) and occupation (blue-collar vs. homemaker, OR = 3.42, CI = 0.09-0.88) whilst patients' interest in seeking WMI was predicted by their disease state (pain/rheumatology condition vs. hypertension, OR = 1.84, CI = 1.11-3.05), health locus of control (powerful other, OR = 0.95, CI = 0.90-0.99) and health literacy levels (adequate vs. inadequate/marginal, OR = 2.7, CI = 1.17-6.39).

CONCLUSIONS

Patients' interest in reading and seeking WMI were influenced by several patient factors including disease state, health locus of control, coping style, health literacy levels and occupation. Furthermore, the results highlighted that reading and seeking WMI were regarded as distinct activities influenced by different factors. These findings may guide health professionals in assessing the utility of WMI for different patient groups and more broadly in the tailoring of patient education to meet patient needs.