When providing written communication to a visually impaired patient it is necessary to use a font typeface that is at least points or greater?

Journal Article

Adriana Chubaty,

1

University of Alberta Hospital

,

Edmonton, Alberta T6G 2B7

,

Canada

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  Adriana Chubaty, Cheryl A. Sadowski, Anita G. Carrie, Typeface legibility of patient information leaflets intended for community-dwelling seniors, Age and Ageing, Volume 38, Issue 4, July 2009, Pages 441–447, https://doi.org/10.1093/ageing/afp065

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Abstract

Introduction

Written patient health information, published by non-profit health organisations, pharmacies, drug companies and regional health authorities, is widely available in clinics and pharmacies across Canada. This written information is commonly prepared for seniors to promote health. Unfortunately, ageing results in clinically significant ophthalmic changes (including reduced accommodation, contrast sensitivity, colour perception, etc.) [1] preventing seniors from accessing some information. Currently one in nine Canadian seniors over age 65 lives with significant vision loss, and this number is expected to grow over the next 10 years as baby boomers in the developed world age [2].

Delivery of written patient information to individuals with low vision, like many seniors, requires special design considerations [3]. Clear print guidelines addressing these considerations have been developed by various library councils, printing houses and foundations for the blind, including the Canadian National Institute for the Blind (CNIB) [4], Royal National Institute for the Blind (RNIB) [5], American Council of the Blind (ACB) [6], American Printing House for the Blind (APH) [7] and the Arlene R. Gordon Research Institute within Lighthouse International [8]. In the USA, an action plan for the provision of useful prescription medicine information was developed in 1996 in an effort to improve oral and written communication regarding prescription medications [9]. The action plan was tested further with two instruments, the Medication Information Design Assessment Scale (MIDAS) and the Consumer Information Rating Form (CIRF) [10]. All of the guidelines have been developed from the small body of research and historical evidence supporting basic theories of typeface legibility. They examine areas such as font, point size, contrast, type colour, heaviness, leading and letter spacing in the document design. The criteria for designing legible written information vary by guidelines but most are comparable. The guidelines have been developed for the English language.

This study describes available written patient health information for seniors, found in clinics and pharmacies in Edmonton, Canada. We sought to determine the extent to which health information available to seniors complies with clear print guidelines.

Methods

Design and Setting

This was a cross-sectional study of patient information leaflets available from community pharmacies and public seniors’ clinics in Edmonton, Canada. Pharmacies were eligible if they were independent, chain or franchise pharmacies and filled prescriptions for the public. Pharmacies located within a hospital or long-term care setting and mail service pharmacies were excluded. Randomised cluster sampling was employed based on the postal code listing for the city of Edmonton. Clusters were defined by the first three digits of the postal code. All pharmacies within each postal code cluster were included except only one location from each chain pharmacy was included once selected. The number of pharmacies in each postal code area varied so clusters were randomly selected until a minimum 20 unique pharmacies were identified. Seniors’ clinics included all publicly funded clinics in Edmonton located at the Misercordia Community Hospital, University of Alberta Hospital and the Glenrose Rehabilitation Hospital. These clinics are accessible to the public and service community-dwelling seniors (age 65+).

Leaflets

Patient information leaflets with drug, disease, health and wellness and health system information intended for seniors (65+) were included. Leaflets pertaining to children, pregnancy, contraception and breastfeeding were excluded by excluding pamphlets which contained the words child, infant, pregnancy, lactation, contraception or their synonyms in the title. Leaflets were included if they were trifold pamphlets, booklets or full pages. Magazines, newspapers and newsletters were excluded. Only English language pamphlets were included.

Leaflet collection

All eligible leaflets (from here on referred to as health leaflets) on display to the public (e.g. waiting rooms, pharmacy counters, displays) were collected from all selected pharmacies and clinics by the investigator (A.C.) until saturation. Saturation was identified by the investigators when no new pamphlets were picked up from the pharmacies. This meant that all possible pamphlets available had been collected. Because little is known about the diversity of pamphlets in Canadian community pharmacies, it was necessary to collect them until saturation.

The investigator also collected a hydrochlorothiazide computer printout prescription leaflet from each community pharmacy. Hydrochlorothiazide leaflets were obtained by request by reciting a scripted statement to the pharmacist. The rationale for collecting the hydrochlorthiazide leaflets is that these types of prescription-associated leaflets are typically given to patients when a medication is dispensed. Because they were available only upon prescription, this necessitated a request to the pharmacist.

Data collection

After collection, similar leaflets (duplicates between different pharmacies or leaflets which used the same format except for colour) were matched to ensure duplicates were analysed once. Matching was performed twice to ensure that all similar leaflets were correctly matched.

The following information was collected about each unique health leaflet: type of information (drug, disease, health and wellness, health system), collection location (pharmacy and/or clinic), producer (pharmaceutical industry, health region, not-for-profit organisation, pharmacy, government, third-party insurer or other).

Leaflets were evaluated on various criteria outlined by recommendations in the CNIB, RNIB and ACB Guidelines (Table 3). The RNIB Guidelines were chosen due to their widespread use in other studies evaluating written leaflets [11, 12]. The CNIB Guidelines were selected as they were developed recently and rigorously, using the best available evidence [4]. The ACB Guidelines, although consensus based, were selected as it was felt that this organisation was most similar to the RNIB and CNIB and thus might guide practice in the USA. Each typeface recommendation in each guideline was included in a data collection tool. The body of every collected leaflet (the part which contained the therapeutic or health information) was visually evaluated as meeting or not meeting each recommendation. Administrative details (fine print) were not considered in the evaluation.

Table 3

Comparison of Guidelines

Table 3

Comparison of Guidelines

Point size was determined by comparing leaflet size to a standardised sample. Documents with body text that contained many different formats for font, point size, contrast, heaviness and leading were classified as meeting a criterion if greater than 80% of the body met that criterion.

Data analysis

Descriptive statistics were used to describe the characteristics of leaflets and to determine the proportion of leaflets meeting each recommendation. Mean scores and standard deviations were calculated for each guideline based on the type of information, and producer. Health and hydrochlorothiazide leaflets were analysed separately.

Results

A total of 757 leaflets were collected from 21 pharmacies and 3 public clinics. After matching similar leaflets, 388 unique health leaflets were evaluated (Table 1). Most leaflets (43.8%) contained disease information. Many leaflets also contained drug (17.8%), health and wellness (19.3%) and health system (19.1%) information. Most leaflets were produced by the pharmaceutical industry (42.8%) or not-for-profit organisations (25%). Pharmacies (12.1%), health regions (9%), government (5.1%) and insurers (2.6%) also produced leaflets.

Table 1

Leaflet adherence guideline recommendations by producer and information type

Table 1

Leaflet adherence guideline recommendations by producer and information type

Leaflet adherence by guidelines

The average number of recommendations met by each health leaflet for the CNIB, RNIB and ACB Guidelines is shown in Table 1. Approximately, 23% of health leaflets met at least 9 of 10 CNIB recommendations, 1% met at least 10 of 11 RNIB recommendations and none met at least 8 of 9 ACB recommendations. Most leaflets met at least half the guideline recommendations with only 1.5, 20.6 and 11.6% of leaflets meeting less than half of CNIB, RNIB and ACB Guideline recommendations, respectively.

Leaflet adherence by producer and information type

Table 1 shows adherence to guideline recommendations separated by leaflet producer and information type, respectively. A similar distribution of adherence to leaflet guidelines is seen across all leaflet producers and information types.

Leaflet adherence by guideline recommendations

Table 2 summarises adherence to guideline recommendations for publicly available leaflets by individual recommendations. Details about specific recommendations are available in Table 3. Few leaflets used at least size 12 font (33.2%). Of the remaining two-thirds of leaflets, many had point sizes smaller than 10. One leaflet providing information for patients on cataracts and age-related macular degeneration was printed with a point size of 6. Few leaflets used appropriate margins (5.9%), paper finish (7.9%) and columns (19.8%) according to the ACB recommendations. Less than half of the leaflets were printed on uncoated paper with no visible text showing through, watermarks or distracting backgrounds. However, most leaflets (97%) used a minimum of 25–30% leading (single spacing between lines). Most leaflet columns and numbers met RNIB Guideline recommendations (100% and 99.5% of leaflets adhered to the criteria, respectively). Most leaflets used standard, plain fonts and avoided use of italics, all capital letters and underlined body text.

Table 2

Adherence to guidelines according to individual criteria

aPamphlets which could not be evaluated on use of columns, navigational aids and numbers were excluded from percentage calculation.

Table 2

Adherence to guidelines according to individual criteria

aPamphlets which could not be evaluated on use of columns, navigational aids and numbers were excluded from percentage calculation.

Hydrochlorothiazide leaflets

Twenty hydrochlorothiazide leaflets were collected from 21 pharmacies. One pharmacy refused to provide a leaflet without a prescription. After matching similar leaflets, 10 unique leaflets were evaluated.

The mean number of recommendations met by hydrochlorothiazide leaflets for the CNIB, RNIB and ACB Guidelines were 6.5, 7.6 and 4.8, respectively. All leaflets met at least half the recommendations for each guideline but only one pamphlet met at least 10 of 11 RNIB recommendations and none met at least 9 or 8 CNIB and ACB Guideline recommendations.

Similar to public leaflets, few hydrochlorothiazide leaflets used the minimum point size in the body of the text. Only three (30%) of these leaflets used at least point size 12 and no leaflet used greater than 16 point size. Eight (80%) of these leaflets used at least 25–30% leading (single spacing); however, only one leaflet used 1.5 spacing between lines. Only one leaflet used columns in the design. Few (30%) of hydrochlorothiazide leaflets used at least 1 inch margins on each side of the text. All leaflets met recommendations for contrast, type colour, heaviness, letter spacing, setting text and numbers under each respective guideline.

Discussion

This study evaluated and described the design of written patient information leaflets for seniors found in community pharmacies and clinics. The design of written medical information is an important consideration as it can reinforce instructions and provide supplemental information [13]. Well-designed written health information is also more likely to be read and valued [14]. Few leaflets collected in this study utilised all the recommendations from the selected guidelines for producing legible written information. Most met at least half of the recommendations made by each respective guideline. Leaflets produced for seniors that were collected in this study were similar in design, regardless of the leaflet producer, or information type.

The prevalence of prescription drug use among seniors is ∼90%, with many seniors requiring a mean of 5.6 medications [15]. This suggests that seniors are frequently exposed to medication labels and prescription drug leaflets, like the hydrochlorothiazide leaflets in this study. Based on the amount of leaflets collected in this study, seniors are exposed to an average of 33 unique health information leaflets with each visit to their pharmacy or outpatient clinic. The legibility of these leaflets is critical for an appropriate dissemination of information. The importance of providing legible information to seniors is particularly critical when addressing topics of a sensitive nature, such as memory problems, erectile dysfunction, financial concerns or elder abuse.

Our results compare to other studies, which have found that 0–50% of leaflets used at least 12 point size [11, 12, 16, 17]. Leaflets in these studies were collected from palliative care units, dentists, hospitals and community pharmacies in the USA and UK. A large study in the USA evaluating 1,360 patient package inserts provided with prescriptions (similar in purpose to hydrochlorothiazide leaflets collected in this study) found that only 3.5% of inserts used at least 12 point size [17]. One study, using a survey to identify patient attitudes about patient package leaflets revealed that 84.6% of respondents over 50 years felt that the print, ranging from size 8 to 14, was too small [16]. Although larger font may limit the amount of information contained on one page, if leaflet producers wish to reach a wider audience they need to consider increasing the point size [4–6].

A more recent study looking at patient package inserts in the USA, consumer medical information in Australia, and patient information leaflets in the UK found that 60–88% leaflets were legible [18]. The leaflets produced in the UK and Australia were most legible likely due to legislation introduced to improve readability and legibility of medication information [18–20]. This legislation applies to all drug monographs provided with prescription and non-prescription medications similar to the hydrochlorothiazide leaflets in this study. It would not apply to the other health information leaflets available in pharmacies and clinics, common in Canada as they formed the bulk of our leaflet samples. As of July 2008, all drug information leaflets in the European Union (EU) are required to undergo user testing ensuring legibility of this written information [19, 21]. It is promising that legislators realise the importance of providing health information in a legible format.

Many factors go into designing legible patient information leaflets. Unfortunately, due to the complexity of designing written information, consensus as to its optimal design has not been established. Even legislation requiring legible drug patient information leaflets is not specific and only provides recommendations [19, 21, 22]. Various library councils, printing houses and foundations for the blind have developed recommendations for designing written information. Most of these guidelines have comparable standards in terms of font, point size, contrast, heaviness, leading and other criteria. In this study, we selected guidelines which were used in previous studies [10, 11], evidence based, geographically representative and had specific recommendations about typeface design to ease applicability of the recommendations and generalisability. Still, a limitation of this study is that these guidelines are typically intended for designing the written material for visually impaired individuals. The organisations which produce these guidelines, however, stress that their recommendations, especially those about font size and leading, are universal and represent a good design sense [4–6]. Not all seniors are visually impaired, but the need to provide legible written health information is universal. Written patient information, especially if intended for seniors, should cater to the lowest denominator in order to reach the widest possible audience. Just as health information or consent forms should be written at a low grade level (e.g. grade 8, the average reading level of a US adult) [23], design should cater to those with reduced vision. Legislation in some parts of the world may help improve the quality of drug information leaflets [18], but other health information leaflets should still be designed with their audience in mind.

One limitation of our study is that the evaluation of guideline recommendations in this study is not intended to provide a score for each leaflet, but rather to describe the spectrum of adherence to typeface design recommendations. We gave equal weight to each recommendation, as did Krass and colleagues [10]. However, legibility depends on a combination of factors and some criteria may be more important than others. There are some additional limitations to the study. The leaflet analysis was completed by one individual, which did not allow for inter-rater confirmation. Also we included only English language pamphlets. Sample size was also a limitation for the hydrochlorothiazide leaflets. The small sample (n = 10) does not allow for assumptions about the design of prescription information. However, there are few software vendors in Canada and the number of duplicates collected in the study suggests that a larger sample may not be available. Another limitation is that many leaflets collected from pharmacies were outdated, some by nearly 10 years. Due to the inclusion of outdated leaflets, the results may not accurately reflect the quality of leaflets being produced today, as the three guidelines were all produced within the last 10 years. However, it is important to note that these leaflets are being distributed in pharmacies and clinics. If the available leaflets have not been updated, access to current health information is still being limited to seniors. Further research is required to determine if leaflet designers are incorporating legibility criteria into new leaflets.

It is important to determine the impact of adherence to design characteristics by testing evaluated leaflets for end users. Two studies evaluated leaflets for consumers [10, 24]. Similar work should be done using typeface recommendations for visually impaired individuals, to evaluate leaflets and their legibility for visually impaired seniors. Legislation in Australia and the EU now require mandatory readability testing of medication leaflets in end users [19–21]. Future work should examine the impact of design criteria and the readability of health information leaflets by seniors.

Key points

• There are published guidelines available to guide the design of written information.

• Leaflets should be designed to meet guidelines that allow for ease of use by individuals with low vision.

• Most leaflets do not meet guideline recommendations.

• Point size is one of the most common recommendation ‘violations’ in regard to the leaflet design.

This project was completed as part of an undergraduate independent research study. No funds were obtained for this study.

Conflicts of interest

The authors have no conflicts of interest to declare.

References

1

. 

Common visual problems: symptoms and treatment, part I

,

Ann Long-Term Care

,

2005

, vol.

13

(pg.

17

-

22

)

2

Canadian National Institute for the Blind

Living with vision loss: a resource for caregivers. (monograph on the Internet)

3

. 

Can you read this?

,

Creat Rev

,

2003

, vol.

23

(pg.

54

-

56

)

4

,  ,  . 

Clear print: an evidence-based review of the research on typeface legibility for readers with low vision (monograph on the Internet)

5

Royal National Institute for the Blind

RNIB clear print guidelines (monograph on the Internet)

6

. 

A guide to making documents visually accessible to people who are blind or visually impaired (monograph on the Internet

7

. 

Large print: guidelines for optimal readability and APHontTM a font for low vision (monograph on the Internet)

8

. 

Making text legible designing for people with partial sight (monograph on the Internet)

9

Steering Committee for the Collaborative Development of a Long-Range Action Plan for the Provision of Useful Prescription Medicine Information

Report submitted to the Honorable Donna E. Shalala, Secretary of the U.S. Department of Health and Human Services (monograph on the Internet). Keystone: The Keystone Committee; December 1996 (cited 20 September 2007) Available from: http://www.fda.gov/cder/Offices/ODS/keystone.pdf

10

,  ,  . 

Using alternative methodologies for evaluating patient medication leaflets

,

Patient Educ Couns

,

2002

, vol.

47

(pg.

29

-

35

)

11

,  . 

An evaluation of the quality of commercially produced patient information leaflets

,

Br Dental J

,

2006

, vol.

201

(pg.

114

-

7

)

12

,  ,  ,  . 

Written information given to patients and families by palliative care units: a national survey

,

Lancet

,

2000

, vol.

355

pg.

1792

13

. 

Providing patients with written health information

,

Ann Pharmacother

,

1998

, vol.

32

(pg.

962

-

9

)

14

,  ,  , et al. 

A systematic review of quantitative and qualitative research on the role and effectiveness of written information available to patients about individual medicines

,

Health Technol Assess

,

2007

, vol.

11:iii

(pg.

1

-

160

)

15

,  ,  . 

Impact of residence on prevalence and intensity of prescription drug use among older adults

,

Ann Pharmacother

,

2006

, vol.

40

(pg.

1932

-

8

)

16

,  ,  . 

Expert and consumer evaluation of patient medication leaflets provided in US pharmacies

,

J Am Pharm Assoc

,

2005

, vol.

45

(pg.

443

-

51

)

17

. 

How readable are the hospital information leaflets available to elderly patients?

,

Age Ageing

,

1994

, vol.

23

(pg.

14

-

6

)

18

,  ,  , et al. 

Content assessment of medicine leaflets from Australia, Europe and the USA

,

J Am Pharm Assoc

,

2007

, vol.

47

(pg.

717

-

24

)

19

European Parliament, Council of the European Union

Consolidated Directive 2001/83/EC of the European Parliament and of the Council of 6 November 2001 on the community code relating to medicinal products for human use as amended by Directive 2002/98/EC, Directive 2004/24/EC and Directive 2004/27/ EC

Brussels, Belgium: European Commission, 2004

20

Department of Health and Ageing

National medicines policy

Canberra, Australia: Commonwealth of Australia, 1999

21

Medicines and Healthcare Products Regulatory Agency Committee on Safety of Medicines

Always read the leaflet (monograph on the Internet)

22

European Commission

Draft guideline on the readability of the label and package leaflet of medicinal products for human use

Revision September 2006. Brussels, Belgium: European Commission, 2006

23

Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association

Health literacy report of the Council on Scientific Affairs

,

JAMA

,

1999

, vol.

281

(pg.

552

-

7

)

24

,  . 

How to improve the readability of the patient package leaflet: a survey on the use of colour, print size and layout

,

Pharmacologic Res.

,

2001

, vol.

43

(pg.

437

-

43

)

© The Author 2009. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email:

Oxford University Press

© The Author 2009. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email:

Topic:

• canada
• organizations
• pharmacies
• guidelines
• older adult
• community
• pharmaceutical company
• community pharmacies
• effective communication

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