Medication nonadherence

The Readability of
Drug-Information Leaflets

picture of ambulence
Ten percent of hospital admissions are due to the failure of following drug instructions.

The failure of patients to take their drugs as directed—medication nonadherence—has been a major health problem ior many years. As the Atlantic reported in 2012, 20 to 30 percent of prescriptions are never filled and 50 percent are not taken as prescribed. There is a direct connecton between taking the drug as prescribed and the success of the treatment.

This failure is the cause in the U.S. alone of 120,000 deaths annually, up to 10 percent of hospital admissions, and an additional US$200 billion in medical costs.

The literacy issue

The problem is usually the result of the failure to communicate instructions in language the patient can easily understand.

Countless studies over the last 50 years have indicated that prescription information is most often too difficult for the average reader. According to national literacy surveys, the average adult reader reads at the 9th-grade level. Nearly 20 percent of adult readers read below the 5th-grade level. Studies have shown that low literacy level is directly related to non-adherence.

As we have often pointed out in this newsletter, the reading ability of seniors often weakens with the loss of short-term memory. Illness also makes reading more difficult. Experts advise that medical information for seniors should be written at the 6th-grade level. Although there has been much improvement in readability in the last several years, printed medical information is still too high for most seniors and patients.

An article from the National Institutes of Health says:

"Given the variability in the capacity to comprehend health-related materials among individuals seeking orthopaedic care, stratifying the contents of patient education materials at different levels of complexity will likely improve health literacy and enhance patient-centered communication...

"Even in the era of mass media such as television, radio, and the Internet, written health information serves many important functions. Giving patients and caretakers written information is vital in reinforcing verbal communication. In an attempt to contain healthcare costs, patients and their caregivers are being given more responsibility in their disease management, making the role of patient education including written information even more critical."

Sources of medical information for patients

There are usually four sources of information for patients taking drugs:

  1. Doctor's verbal instructions.
  2. The package label.
  3. The printed package insert.
  4. Printed and digital supplements.
  5. Video clips.
  6. Mobile apps

1. Doctor's verbal instructions.

The best way to improve medication adherence and treatment outcomes is to improve the communication between the doctor and patients. Seniors have special problems. They not only suffer from loss of hearing but also of short-term menory, which hinders their ability to process language.

Over the years, countless articles have urged doctors to improve their skills in communicating with patients:

2. Package label

The package label is the chief printed information available to the patient at the point of use. The labels on both over-the-counter and prescription drugs are still too difficult for many readers. Although the format and content of drug labels have been extensively regulated, there has been little improvement in their readability.

In this 2006 study, nearly half (46.3%) were unable to read and correctly state one or more of the label instructions on five common prescriptions. Rates of misunderstanding were higher among patients with marginal and low literacy.

3. Package inserts

Click to enlarge
Nitrostat package insert
A package insert for Nitrostat, a popular remedy for chest pains. The technical and patient information on the same page will discourage many readers.

Printed drug inserts are prepared by the drug makers and are key sources of knowledge about the drugs, but they have many problems.

One study recommends a reassessment of both their design and readability.

The inserts are too difficult for the average reader because:

1. They contain both technical information and instructions for patients. Addressing different audiences on separate pages would be a big improvement.

2. The information is often incomplete and badly organized, failing to prioritze what information is most important.

3. They lack a simple and inviting design with color and graphics that would greatly improve readability.

Inserts would be much more effective if the patient information would prioritize important information and were limited to only what the patient needs to know, namely:

  1. The name of the drug and its size.
  2. Purpose and indications for use.
  3. Dosage and schedule.
  4. Warnings about effects of misuse and non-adherence.
  5. Possible side effects and remedies to take. e.g., "contact your doctor."

The size of the page should be large enough to accommodate a readable typeface and a design that emphasizes the most important points to remember.

3. Printed and online leaflets

In the 1970s, in response to the difficulty of the package inserts, nurses began supplementing the package insert by writing simpler instructions on separate pages, often called "medical information leaflets." Private companies soon took over that task. Supplying printed and online leaflets for pharmacists to distribute has become big business.

A 1997 British study on patient-information leaflets states:

This 2015 Brazilian study also recommends that writers go beyond just using a readability score and develop different formats and designs, include illustrations, and test the document on real patients.

Extensive studies have shown that illustrations, even simple pictograms, improve comprehension, retention, and recall of medical information.

Illustrations are especially effective when used in combination with verbal and written instructions, and when used to explain the name, dosage, and timing for new and unfamiliar drugs.

It is always important to pilot test the images to maximize their relevance and clarity, especialy when using them across several cultures.

It should be noted that many states now require pharmacists to have a conversation with customers to determine their level of understanding of the requirements in taking a specific drug.

4. Video clips

Cancer video

"The Fine Print of Cancer," one of a series of patient videos prepared by Johns Hopkins.

Videos demonstrating correct medical procedureshave become very common. Here are two reports on the effectiveness of videos in improving communication with patients:

Such videos can also be posted online for later use. Videos watched by patients in the doctor's office are much more effective if they are followed by a discussion with the doctor or nurse to determine the level of the patient's understanding.

5. Mobile apps

Doctor on iPad
Some companies such as Push Doctor in UK are offering an iPad app for online consultation with a doctor.

There are also apps for tablets and smartphones available at drugs.com.

Patients can uee them at home for identifying drugs and listing their uses and interactions.

They would be much more useful if the doctor or nurse could customize them for individual use.

Again, mobile apps are no substitute for a conversation with the health provider to determine the patient's level of understanding.

Plain language in the news

Dr. Fullerton's use of plain language in patient notes: http://tinyurl.com/nnbleqx

SEC Federal plain-language report:http://tinyurl.com/q83gpcs

Judge's surprising plain-language sentencing report: http://tinyurl.com/pmnxhs3

Law for the Common Man: http://tinyurl.com/prcuwm2

Art and skill of readable numismatic writing: http://tinyurl.com/lzs8r88

Resume tips for government job seekers: http://tinyurl.com/kedkasd

Readability scores for science students: http://tinyurl.com/kcsb5jn

Readability of college assessment tests: http://tinyurl.com/nqskdfp

Grading the readability of the Federal Reserve: http://tinyurl.com/q4uwdve

How jargon ruins comunications: http://tinyurl.com/nmub2ux

Health Websites too difficult to read: http://tinyurl.com/ppejhrn

Murky press releases conceal poor results: http://tinyurl.com/n938npr

Readability of American presidents: http://tinyurl.com/nssgrnl

How to write a paper in marine science: http://tinyurl.com/qjzurq4

Singapore requires plain language in investment documents: http://tinyurl.com/ov7edtx

UN climate-change summaries too difficult to read: http://tinyurl.com/j8bemjo

Problems in charity Websites: http://tinyurl.com/z4hhyn5

Improve the readability of your firm's blog: http://tinyurl.com/q6wyudd

Patients leaving hospitals don't understnd care plans: http://tinyurl.com/zst62a8

The difficulty of End User Agreements: http://tinyurl.com/oxbtfey

A plain-language environmental assssment: http://tinyurl.com/jho3yps

Program matches books with students' reading levels: http://tinyurl.com/gpmzqbv

Bad writing hurts your business: http://tinyurl.com/h6pgvly