This story is part of an ongoing campaign called theAlphabet of Illiteracy. By using letters themselves—the foundation of reading and writing—Project Literacy examines the ways illiteracy underpins some of the greatest challenges facing the world today. Below, we explore the letter O for “overdose.”
Target's clearly legible prescription labels were designed by a School of Visual Arts graduate—and they’re the exception in the United States. Image via (cc) Flickr user Bart.
Think about your most recent prescription medication bottle. The colors, symbols, fonts, and information contained there each served a specific purpose. But was that information understandable?
For many people, it’s not. Half of U.S. patients don't understand the health information they receive, according to an estimate by the American Medical Association. The average American reads at an eighth-grade level, whereas most healthcare information, including labels on prescriptions, is written for college graduates. And that doesn't even take into consideration people who struggle with English as a second language.
“If I could get the word ‘twice’ off every prescription bottle in America, I could retire,” says Dr. Ruth Parker, a clinician and professor at Emory University in Atlanta. “It’s a simple word to pronounce and say, but what does twice even mean? 8 a.m. and 4 p.m.? Morning and evening? It doesn’t make any sense.”
Parker is part of a research movement to redesign the prescription bottle label. According to a 2010 study, 75 percent of U.S. adults can’t fully identify a prescription’s indication for use, leading to non-adherence and poorer health outcomes. For older adults who receive an average of 27 prescriptions per year, written by up to eight different providers, the problems can be even more stark.
Though health illiteracy is a global phenomenon, the trouble with prescription labels themselves may be most pronounced in the United States. In Europe, medication is rarely dispensed in “loose pill” form (placed in amber vials as they are in America), says Michael Wolf, a researcher at Northwestern University in Evanston, Illinois. Rather, a “unit of dose delivery” (a single dose per package) is more common. “That creates a bit of a change compared to here, especially in terms of labeling.” An international meeting planned for this summer in Buenos Aires will address a global perspective on labeling, and the need for cultural awareness.
“A prescription drug label is the last form of communication we have between the patient and the provider,” says Anandi Law, a researcher at Western University of Health Sciences in Pomona, California. “Patients have to be able to translate all that information into action.” According to a 2006 Institute of Medicine report, an estimated 1.5 million preventable adverse drug events in the U.S.—including overdose, non-adherence, and interactions—occur every year, costing nearly $1 billion.
One of the problems is that different states have different mandates about what should be on a label. In fact, there are 31 slightly tweaked label variations in the United States. When Wolf ran a study and filled 100 different prescriptions around the country, he saw firsthand how disparate the labeling is.
In some cases, Wolf noticed how big the pharmacy logo was compared with the rest of the info. His work led to creating a more evidence-based label, ditching some of the widely used but ineffective language like that dreaded word “twice” and moving to a system that’s easier to digest.
Wolf and colleagues tested their “enhanced prescription label,” which tells patients when to take their meds depending on the time of day by using a picture of a pillbox. They tested this model and found that it improved outcomes, especially in low-literacy patients.
He says that relatively simple tweaks could improve understanding, prioritizing content over logos and making sure that fonts are large enough to be legible even by aging eyes. Anything below a size 10 font is pretty difficult to understand, Wolf says.
There’s an ongoing debate about whether the prescription label should indicate what the medicine is for, be it diabetes or high blood pressure. Patients have asked that labels show the illness that the medication treats, but that information has to be added by a physician at the time of prescribing—a pharmacist can’t add it later.
Law has also tested different labels for understanding, and published the results in 2010 (her team is preparing a new paper for publication that shows similar results). She found that using different colors to offset the various parts of the label helped people understand the information better. The majority of people surveyed preferred the new labels over conventional ones.
In addition, Law and a graduate student studied a program that used pharmacists to walk patients through the parts of a prescription label, pointing out the relevant sections and explaining how to use the information found there. They discovered that education, even if it’s only 10 minutes per patient, along with redesigned labels could play a significant role in improving health literacy.
“Most people don’t get a lot of information from their doctor,” explained Wolf. “If you’re not getting what you need from your doctor and the prescription drug label is a throwaway, then it’s easy to see how adverse reactions happen. We can get a lot of bang for our healthcare buck by redesigning something as simple as a drug label and a prescription.”
In California, state legislators have passed laws mandating clearer labels and the inclusion of multiple languages—something the researchers say is a step in the right direction. Both Wolf and Law have testified in front of the pharmacy board of California in support of evidence-based labeling.
“We should eventually have a national model for labels,” says Wolf. “That would be the ideal situation.” Consistent messaging in familiar language that’s easy to understand no matter one’s literacy level will be a huge first step in ensuring that all patients remain safe and healthy—and set up for success in the future.
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