- Email: [email protected]
Patient Education Materials: Suggestions for Improvement
Consumer Advisory Board Report
Patient Education Materials: Suggestions for Improvement Introduction n recent years the ph arm aceutical industry has responded to th e growi ng emphasis on t he pha rmacist's role as patient educator by providing pharmacists with a variety of patient education materials. For the most part these materials are printed matter, such as pamphlets and patient medication instructions. Recognizing that the value of these pieces is often li m ited , an independent consumer advisory board* of experts in communication, pharmacy education , patient counseling, and pha rmaceutical manufact uring met in Atlanta during th e 1988 Annual Meeting of the America n Pharmaceutical Association t o discuss ways to improve th em.
I
* T he Consumer E ducation Guidelines Advisory Board consists of Maurice Q. Bectel, president, Pharmaceutical Manufacturers A ssociation Foundation; Philip P. Gerbino, PharmD, professor of clinical pharmacy, associate dean of pharmacy, and executive director, Geriatric Pharmacy Institute at the Philadelphia College of Pharmacy and S cience; William M. Heller, PhD, executive director, United States Pharmacopeial Convention; Samuel H. Kalman, director ofeducation and development, American Pharmaceutical Association; Dorothy L . Smith , PharmD, president, Consumer Health Information Corp.; Tlwmas H. Atherton, general manager, Medical Education Division, Healthways Communications, Inc.; Lawrence C. Weaver, PhD, vice-president, professional relations, Pharmaceutical Manufacturers Association; Frances M. West, Secretary for Community Affairs, State of Delaware; and Margaret C. Yarborough , MS, Director, Diabetes Care Center, Cary, N.C.
34
Highli ghts of the board's discussion are presented here, including its suggestions for developing effective pa tient education materials that clearly explain the appropriat e use of medication s. These suggestions are in no way comprehensive; they are intended as a starting point for further discussion. The board's goal is to develop a clear-cut set of guidelines to present to pharmaceutical manufactur-
Today most materials available are informational or promotional; very few are really designed to help users in their medication taking. ers and other groups that prepare patient education materials. Although the board centered its discussion on print materials, it noted that the principles discussed here affect all forms of communication , including oral counseling, audiotape, videotape, and film.
Considerations
R
esearch in the area of patient education materials generally has focused on delineating areas of need and on making an inventory of available materials. It has looked at style, design, and production of printed pieces but has rarely focused on the fundamental princi-
pIes of education that bring about behavioral changes in people . These fundamental principles should be considered at the conceptual stage. Before an educational piece is developed, its focus must be clearly established. For example, is the primary goal to convey information or to effect behavioral change? Today most materials available are informational or promotional; very few are really designed to help users in their medication taking. The most useful educational materials are those that support t he practitioner's efforts to influence attitude, beh avior, and opinion.
Content Orientation The content of the materials may be developed around the disease, the drugs used to treat the disease, or both. Regardless of the approach, the orientation should be readily identifiable for the benefit of the practi tioner. Short pieces have a stronger impact when they are developed with a single content orientation. Today most materials geared specifically for pharmacists' use tend to be drugoriented, with the exception of some support pieces for nonprescription products. These latter materials are typically disease-oriented and provide little drug information. However, as awareness of diseasedrug and drug -drug interactions involving nonprescription drugs grows and pharmacists gain increasing responsibility for alerting patients to potential interactions, the need for more nonprescription drug information is becoming acute.
American Pharmacy, Vol. NS29, No. 10 October 1989/65(
Consistency of Sources ~lt~ough readers may vary in theIr Interpretation of infonnation contained in educational materials patients are less likely to be con~ fused if all the materials they receive rely on the same standard reference sources. For example, both the American Medical Association (AMA) and NARD (fonnerly the National Association of Retail Druggists) base their materials on the U8PDI; therefore, the written descriptions of drugs are the same in AMA and NARD leaflets. By using these materials, physicians and pharmacists are able to present their respective information to the same patients without confusing them.
Pre enting medical infonnation to those who lack education or are illiterate is one obvious challenge that must be faced; however, pitfalls also exist in conveying infonnation to educated patients. Although the latter group may be capable of reading at a very high level, it is best to aim for a lower level - without oversimplifying or appearing condescending. Finding an effective approach is more difficult when the audience is large and comprises varied backgrounds and educational levels (e.g., diabetics). Difficulties with language are less likely when targeting a rather defined group (e.g., college students on the topic of sexually transmitted diseases).
Target Audience Each educational piece must have a clearly defined target audience. Although practitioners agree that the specialized needs of patient subgroups - such as adolescents and the elderly - deserve more attention, pharmaceutical marketing strategies and cost considerations often cause materials to be geared for a broad audience. Specialized materials are a great help to pharmacists, nurses, and physicians as they strive to educate and provide reinforcement to target groups, but unfortunately few such materials exist. An example of the type of approach needed is the American Lung Association's antismoking program for pregnant women, which targets a particular risk factor in a well-defined patient population and is directed toward a specific behavior change and a positive goal- a healthy infant. Until pharmaceutical companies and communications firms start producing targeted materials, they should consider providing health professionals with instructions for tailoring general materials to specific groups.
Language Language considerations depend on the target audience. Information written for the general public is best understood if it is conveyed in lay language. Doing so does not mean that accuracy and completeness have to be sacrificed.
Strong, positive images that guide the patient toward desirable behavior are more effective than negative-images.
Sty·le and Tone The type of motivational andeducational approach aimed for infl uences the overall style of a piece. D se of fear or scare tactics as in warning a smoker of the lik~lihood of lung cancer, results in a negative tone. Enlisting patients as the major participants in the team effort to meet a desirable health goal conveys a more positive and supportive tone. In general, a more direct tone, which at the same time solicits the patient's cooperation, is desirable for educational pieces. Toward this end, the use of the active voice, in which the person performing the action is clearly identifiable, is preferable to the passive voice. For example,"Be sure you finish all the medicine" is more direct and effective than '~ll the medicine must be finished."
Publication Design Optimal presentation of educational material also depends on the
American Pharmacy, Vol. NS29, No. 10 October 1989/651
appearance of the printed piece use of appropriate color, typeface, layout, and graphic design. Certain target groups require special consideration. For example, the elderly and the visually impaired need materials with large, readable type on a white background, surrounded by wide margins. Typically, sans serif type (which has no strokes on the letters to help the eye move across the page) and justified type (columns that are aligned evenly on both sides) make copy harder to read. Graphics should be used to enhance the educational message and not just to decorate. Strong, positive images that guide the patient toward desirable behavior are more effective than negative images. For example, showing a patient the positive concept of a designated nondrinking driver is more effective than showing the stark consequences of drinking and driving. Certain colors appear to evoke different responses among patients. For example, in a recent survey, the color red was associated with blood and illness, whereas blue was perceived as soothing.
A Progressive-Approach Heal th professionals understand the need for various types ofmaterials and different levels of information, especially in managing chronic conditions. In diabetes education for example, materials relating t~ basic needs, such as urine testing and insulin administration, are readily available. However, materials dealing with more complex issues, such as managing the disease at home and motivating patients to change their lifestyle, are not readily available. Patient education must 'be progressive to keep in step with the patients' readiness to learn about their illness. Patients need time to absorb material about their disease and about their role in the multiple aspects of its management. Educating the newly diagnosed. diabetic may begin with establishing a context for the condition and teaching basic skills related to survival. From this point, a progression of educational activities - from basic to advanced - is needed to achieve 35
pennanent changes in patient behavior. Reinforcement, which is rarely addressed in patient education programs, is integral to the education process. The proven successes of direct mail advertising techniques suggest ways to encourage patient participation. Patient education materials also need to be open-ended, reflecting the cooperative approach to health care and the progressive nature of the educational process. A tiered approach, which gives specific options to patients who want further guidance, is extremely useful.
Categorization of Materials Most producers of educational
materials do not give a clear indication of a piece's focus, goals, target audience, and reading level. Such infonnation would greatly aid pharmacists selecting appropriate materials for use with patients. Including the year of publication on materials would help the phannacist eliminate those that are dated.
Conclusion he suggestions outlined here are but a beginning toward change. T The next step is to gather comments from phannacists and others concerned about patient education, and to develop comprehensive guidelines. Then, with the cooperation of the phannaceutical industry and
other producers of patient educa. tion materials, phannacists may see the emergence of focused materi· als designed to meet the specific needs of differing audiences. ®
If you have suggestions for improving the patient educa\Wtiol\ma~rials supplied by the pharmaceutical indusF/try, aUI~a~e send;~h . em to: ~ PRUip ~w Ger51n(;) Philadelphia College of &;" acy al}d Science (;) lmiH Ave. at 43rd St. I"" r~~~lfFa,£A 19104
AVAILABLE THROUGH APhA FOR THE FIRST TIME!
!5!f!!s~ha2£~~~atrolicy Manual,
6th Edition
·lsed I• ~ gui~e, comp~ed?y the ~sas Phannacists As~ociation, provides you Newly rev WIth easily accessIble information to help you expedite returns. The policies of 248 different companies are listed, along with step-by-step procedures for returning merchandise to each one. Forty new companies and 30 pages were added to .this year's edition. Of the companies in the last edition, 170 changed their policies in the past year. Many companies also added toll-free numbers for processing returns. With this new edition, you'll be up-to-date on all these changes. You'll save time and avoid headaches with the information you'll find in the Return Goods Policy Manual!
®
270 pages 0 Soft cover 0 Published September 1989 0 Code AP10-T46 0 $35
APhA
The Return Goods Policy Manual, developed by the Kansas Pharmacists Association, paid for itself several times over the first month we had it. Boehringer Mannheim, the Accu-Chek people, had sent me several hundred dollars' worth of merchandise as part of their opening order, which their local representative informed me could not be returned when it became outdated. Our first review of Return Goods Policy Manual led us to Boehringer's return policy. We confronted our representative with the discrepancy between his statement and his company's written policy and - presto - a $600 credit! LN. ("Red") Camp, Pharmacist, Camp Pharmacy, President, Florida Pharmacy Association
[2] Yes, I want the new edition of the Return Goods Policy Manual so that I'll have all this valuable information in one place! Send me _ _ _ copies at $35 each for a total of $ _ _ _ __
o My check payable to APhA is enclosed.
Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
o Charge my: 0
Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
VISA 0 MasterCard 0 American Express
Card No. _ _ _ _ _ _ _ _ _ _ _ Expires _ __
City _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Signature _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
State _ _ _ _ _ _ _ _ ZIP _ _ _ _ _ _ __
Return to: APhA Order Desk, 2215 Constitution Ave., NW, Washington DC 20037 or call toll free (800) 237-2742.
36
APIO-T46
American Pharmacy, Vol. NS29, No. 10 October 1989/652
Patient Education Materials: Suggestions for Improvement Introduction n recent years the ph arm aceutical industry has responded to th e growi ng emphasis on t he pha rmacist's role as patient educator by providing pharmacists with a variety of patient education materials. For the most part these materials are printed matter, such as pamphlets and patient medication instructions. Recognizing that the value of these pieces is often li m ited , an independent consumer advisory board* of experts in communication, pharmacy education , patient counseling, and pha rmaceutical manufact uring met in Atlanta during th e 1988 Annual Meeting of the America n Pharmaceutical Association t o discuss ways to improve th em.
I
* T he Consumer E ducation Guidelines Advisory Board consists of Maurice Q. Bectel, president, Pharmaceutical Manufacturers A ssociation Foundation; Philip P. Gerbino, PharmD, professor of clinical pharmacy, associate dean of pharmacy, and executive director, Geriatric Pharmacy Institute at the Philadelphia College of Pharmacy and S cience; William M. Heller, PhD, executive director, United States Pharmacopeial Convention; Samuel H. Kalman, director ofeducation and development, American Pharmaceutical Association; Dorothy L . Smith , PharmD, president, Consumer Health Information Corp.; Tlwmas H. Atherton, general manager, Medical Education Division, Healthways Communications, Inc.; Lawrence C. Weaver, PhD, vice-president, professional relations, Pharmaceutical Manufacturers Association; Frances M. West, Secretary for Community Affairs, State of Delaware; and Margaret C. Yarborough , MS, Director, Diabetes Care Center, Cary, N.C.
34
Highli ghts of the board's discussion are presented here, including its suggestions for developing effective pa tient education materials that clearly explain the appropriat e use of medication s. These suggestions are in no way comprehensive; they are intended as a starting point for further discussion. The board's goal is to develop a clear-cut set of guidelines to present to pharmaceutical manufactur-
Today most materials available are informational or promotional; very few are really designed to help users in their medication taking. ers and other groups that prepare patient education materials. Although the board centered its discussion on print materials, it noted that the principles discussed here affect all forms of communication , including oral counseling, audiotape, videotape, and film.
Considerations
R
esearch in the area of patient education materials generally has focused on delineating areas of need and on making an inventory of available materials. It has looked at style, design, and production of printed pieces but has rarely focused on the fundamental princi-
pIes of education that bring about behavioral changes in people . These fundamental principles should be considered at the conceptual stage. Before an educational piece is developed, its focus must be clearly established. For example, is the primary goal to convey information or to effect behavioral change? Today most materials available are informational or promotional; very few are really designed to help users in their medication taking. The most useful educational materials are those that support t he practitioner's efforts to influence attitude, beh avior, and opinion.
Content Orientation The content of the materials may be developed around the disease, the drugs used to treat the disease, or both. Regardless of the approach, the orientation should be readily identifiable for the benefit of the practi tioner. Short pieces have a stronger impact when they are developed with a single content orientation. Today most materials geared specifically for pharmacists' use tend to be drugoriented, with the exception of some support pieces for nonprescription products. These latter materials are typically disease-oriented and provide little drug information. However, as awareness of diseasedrug and drug -drug interactions involving nonprescription drugs grows and pharmacists gain increasing responsibility for alerting patients to potential interactions, the need for more nonprescription drug information is becoming acute.
American Pharmacy, Vol. NS29, No. 10 October 1989/65(
Consistency of Sources ~lt~ough readers may vary in theIr Interpretation of infonnation contained in educational materials patients are less likely to be con~ fused if all the materials they receive rely on the same standard reference sources. For example, both the American Medical Association (AMA) and NARD (fonnerly the National Association of Retail Druggists) base their materials on the U8PDI; therefore, the written descriptions of drugs are the same in AMA and NARD leaflets. By using these materials, physicians and pharmacists are able to present their respective information to the same patients without confusing them.
Pre enting medical infonnation to those who lack education or are illiterate is one obvious challenge that must be faced; however, pitfalls also exist in conveying infonnation to educated patients. Although the latter group may be capable of reading at a very high level, it is best to aim for a lower level - without oversimplifying or appearing condescending. Finding an effective approach is more difficult when the audience is large and comprises varied backgrounds and educational levels (e.g., diabetics). Difficulties with language are less likely when targeting a rather defined group (e.g., college students on the topic of sexually transmitted diseases).
Target Audience Each educational piece must have a clearly defined target audience. Although practitioners agree that the specialized needs of patient subgroups - such as adolescents and the elderly - deserve more attention, pharmaceutical marketing strategies and cost considerations often cause materials to be geared for a broad audience. Specialized materials are a great help to pharmacists, nurses, and physicians as they strive to educate and provide reinforcement to target groups, but unfortunately few such materials exist. An example of the type of approach needed is the American Lung Association's antismoking program for pregnant women, which targets a particular risk factor in a well-defined patient population and is directed toward a specific behavior change and a positive goal- a healthy infant. Until pharmaceutical companies and communications firms start producing targeted materials, they should consider providing health professionals with instructions for tailoring general materials to specific groups.
Language Language considerations depend on the target audience. Information written for the general public is best understood if it is conveyed in lay language. Doing so does not mean that accuracy and completeness have to be sacrificed.
Strong, positive images that guide the patient toward desirable behavior are more effective than negative-images.
Sty·le and Tone The type of motivational andeducational approach aimed for infl uences the overall style of a piece. D se of fear or scare tactics as in warning a smoker of the lik~lihood of lung cancer, results in a negative tone. Enlisting patients as the major participants in the team effort to meet a desirable health goal conveys a more positive and supportive tone. In general, a more direct tone, which at the same time solicits the patient's cooperation, is desirable for educational pieces. Toward this end, the use of the active voice, in which the person performing the action is clearly identifiable, is preferable to the passive voice. For example,"Be sure you finish all the medicine" is more direct and effective than '~ll the medicine must be finished."
Publication Design Optimal presentation of educational material also depends on the
American Pharmacy, Vol. NS29, No. 10 October 1989/651
appearance of the printed piece use of appropriate color, typeface, layout, and graphic design. Certain target groups require special consideration. For example, the elderly and the visually impaired need materials with large, readable type on a white background, surrounded by wide margins. Typically, sans serif type (which has no strokes on the letters to help the eye move across the page) and justified type (columns that are aligned evenly on both sides) make copy harder to read. Graphics should be used to enhance the educational message and not just to decorate. Strong, positive images that guide the patient toward desirable behavior are more effective than negative images. For example, showing a patient the positive concept of a designated nondrinking driver is more effective than showing the stark consequences of drinking and driving. Certain colors appear to evoke different responses among patients. For example, in a recent survey, the color red was associated with blood and illness, whereas blue was perceived as soothing.
A Progressive-Approach Heal th professionals understand the need for various types ofmaterials and different levels of information, especially in managing chronic conditions. In diabetes education for example, materials relating t~ basic needs, such as urine testing and insulin administration, are readily available. However, materials dealing with more complex issues, such as managing the disease at home and motivating patients to change their lifestyle, are not readily available. Patient education must 'be progressive to keep in step with the patients' readiness to learn about their illness. Patients need time to absorb material about their disease and about their role in the multiple aspects of its management. Educating the newly diagnosed. diabetic may begin with establishing a context for the condition and teaching basic skills related to survival. From this point, a progression of educational activities - from basic to advanced - is needed to achieve 35
pennanent changes in patient behavior. Reinforcement, which is rarely addressed in patient education programs, is integral to the education process. The proven successes of direct mail advertising techniques suggest ways to encourage patient participation. Patient education materials also need to be open-ended, reflecting the cooperative approach to health care and the progressive nature of the educational process. A tiered approach, which gives specific options to patients who want further guidance, is extremely useful.
Categorization of Materials Most producers of educational
materials do not give a clear indication of a piece's focus, goals, target audience, and reading level. Such infonnation would greatly aid pharmacists selecting appropriate materials for use with patients. Including the year of publication on materials would help the phannacist eliminate those that are dated.
Conclusion he suggestions outlined here are but a beginning toward change. T The next step is to gather comments from phannacists and others concerned about patient education, and to develop comprehensive guidelines. Then, with the cooperation of the phannaceutical industry and
other producers of patient educa. tion materials, phannacists may see the emergence of focused materi· als designed to meet the specific needs of differing audiences. ®
If you have suggestions for improving the patient educa\Wtiol\ma~rials supplied by the pharmaceutical indusF/try, aUI~a~e send;~h . em to: ~ PRUip ~w Ger51n(;) Philadelphia College of &;" acy al}d Science (;) lmiH Ave. at 43rd St. I"" r~~~lfFa,£A 19104
AVAILABLE THROUGH APhA FOR THE FIRST TIME!
!5!f!!s~ha2£~~~atrolicy Manual,
6th Edition
·lsed I• ~ gui~e, comp~ed?y the ~sas Phannacists As~ociation, provides you Newly rev WIth easily accessIble information to help you expedite returns. The policies of 248 different companies are listed, along with step-by-step procedures for returning merchandise to each one. Forty new companies and 30 pages were added to .this year's edition. Of the companies in the last edition, 170 changed their policies in the past year. Many companies also added toll-free numbers for processing returns. With this new edition, you'll be up-to-date on all these changes. You'll save time and avoid headaches with the information you'll find in the Return Goods Policy Manual!
®
270 pages 0 Soft cover 0 Published September 1989 0 Code AP10-T46 0 $35
APhA
The Return Goods Policy Manual, developed by the Kansas Pharmacists Association, paid for itself several times over the first month we had it. Boehringer Mannheim, the Accu-Chek people, had sent me several hundred dollars' worth of merchandise as part of their opening order, which their local representative informed me could not be returned when it became outdated. Our first review of Return Goods Policy Manual led us to Boehringer's return policy. We confronted our representative with the discrepancy between his statement and his company's written policy and - presto - a $600 credit! LN. ("Red") Camp, Pharmacist, Camp Pharmacy, President, Florida Pharmacy Association
[2] Yes, I want the new edition of the Return Goods Policy Manual so that I'll have all this valuable information in one place! Send me _ _ _ copies at $35 each for a total of $ _ _ _ __
o My check payable to APhA is enclosed.
Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
o Charge my: 0
Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
VISA 0 MasterCard 0 American Express
Card No. _ _ _ _ _ _ _ _ _ _ _ Expires _ __
City _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Signature _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
State _ _ _ _ _ _ _ _ ZIP _ _ _ _ _ _ __
Return to: APhA Order Desk, 2215 Constitution Ave., NW, Washington DC 20037 or call toll free (800) 237-2742.
36
APIO-T46
American Pharmacy, Vol. NS29, No. 10 October 1989/652