Patient misunderstanding of instructions on prescription drug labels is common and a likely cause of medication error and less effective treatment.To test whether the use of more explicit language to describe dose and frequency of use for prescribed drugs could improve comprehension, especially among patients with limited literacy.Cross-sectional study using in-person, structured interviews.Three hundred and fifty-nine adults waiting for an appointment in two hospital-based primary care clinics and one federally qualified health center in Shreveport, Louisiana; Chicago, Illinois; and New York, New York, respectively.Correct understanding of each of ten label instructions as determined by a blinded panel review of patients' verbatim responses.Patient understanding of prescription label instructions ranged from 53% for the least understood to 89% for the most commonly understood label. Patients were significantly more likely to understand instructions with explicit times periods (i.e., morning) or precise times of day compared to instructions stating times per day (i.e., twice) or hourly intervals (89%, 77%, 61%, and 53%, respectively, p < 0.001). In multivariate analyses, dosage instructions with specific times or time periods were significantly more likely to be understood compared to instructions stating times per day (time periods - adjusted relative risk ratio (ARR) 0.42, 95% Confidence Interval (CI) 0.34-0.52; specific times - ARR 0.60, 95% CI 0.49-0.74). Low and marginal literacy remained statistically significant independent predictors of misinterpreting instructions (low - ARR 2.70, 95% CI 1.81-4.03; marginal -ARR 1.66, 95% CI 1.18-2.32).Use of precise wording on prescription drug label instructions can improve patient comprehension. However, patients with limited literacy were more likely to misinterpret instructions despite use of more explicit language.

Background. Smoking during pregnancy increases the health risks of the unborn child as well as the mother. Although smoking rates for the population as a whole have declined drastically in the past generation, since 1992 there has been an increase in smoking among women, teenagers, and adults living in poverty. The purpose of this study was to assess reading level, tobacco knowledge, attitudes, and practices of tobacco use among pregnant adult and adolescent women in the public health system in north Louisiana. Methods. A convenience sample of 600 pregnant women was interviewed in person in the Obstetrics Clinics at Louisiana State University Health Sciences Center at Shreveport and E.A. Conway in Monroe. The structured interview contained detailed questions about smoking practices, tobacco knowledge, and attitudes. Reading was assessed using the Rapid Estimate of Adult Literacy in Medicine. Smoking practices were assessed by self-report and verified by measuring urine cotinine levels. The Cochran-Mantel-Haenszel test was used to estimate the relationship between reading level and knowledge and attitude; multiple logistic regression was used to determine which variable(s) predicted current smoking practices. Results. Knowledge about the effects of smoking and concern about the health effect of smoking on their baby varied significantly by reading level, with participants with higher reading levels having more knowledge and greater concern. Smoking practices did not vary by reading level even when race, age, and living with a smoker were controlled. Race was a significant determinant of smoking practices, with more white women reporting currently smoking during pregnancy than African Americans (34% vs 8%). Conclusions. Reading level was related to knowledge about health effects of smoking. Women with higher reading levels were also more concerned about the adverse health effects of smoking on themselves and their babies. However, reading level was not correlated with smoking prevalence. The most significant determinant of smoking was race (with whites smoking significantly more than African Americans).

OBJECTIVE: To study the effects of three approaches to increasing utilization of screening mammography in a public hospital setting in Northwest Louisiana. DESIGN: Randomized intervention study. POPULATION: Four hundred forty-five women aged 40 years and over, predominantly low-income and with low literacy skills, who had not had a mammogram in the preceding year. INTERVENTION: All interventions were chosen to motivate women to get a mammogram. Group 1 received a personal recommendation from one of the investigators. Group 2 received the recommendation plus an easy-to-read National Cancer Institute (NCI) brochure. Group 3 received the recommendation, the brochure, and a 12-minute interactive educational and motivational program, including a soap-operastyle video, developed in collaboration with women from the target population. MEASUREMENTS AND MAIN RESULTS: Mammography utilization was determined at 6 months and 2 years after intervention. A significant increase (p=.05) in mammography utilization was observed after the intervention designed in collaboration with patients (29%) as compared with recommendation alone (21%) or recommendation with brochure (18%) at 6 months. However, at 2 years the difference favoring the custom-made intervention was no longer significant. CONCLUSIONS: At 6 months there was at least a 30% increase in the mammography utilization rate in the group receiving the intervention designed in collaboration with patients as compared with those receiving the recommendation alone or recommendation with brochure. Giving patients an easy-to-read NCI brochure and a personal recommendation was no more effective than giving them a recommendation alone, suggesting that simply providing women in a public hospital with a low-literacy-level, culturally appropriate brochure is not sufficient to increase screening mammography rates. In a multivariate analysis, the only significant predictor of mammography use at 6 months was the custom-made intervention.

Background. Medical information pamphlets often are written using language that requires a reading level higher than parents of many pediatric patients have achieved. Anecdotal reports suggest that many parents may not readily understand the federally mandated Public Health Service vaccine information pamphlets prepared by the Centers for Disease Control and Prevention (CDC) in 1991. The level at which the pamphlets need to be written for low-reading-level parents is undetermined as is whether parents reading at higher levels will accept low-reading-level materials.Methods. To determine whether a simple pamphlet prepared at a low reading level using qualitative and adult education techniques would be preferable to the available CDC polio vaccine information pamphlet, we conducted an integrated qualitative-quantitative study. We compared the parent reading time and comprehension of a simplified pamphlet (Louisiana State University, LSU) comprising 4 pages, 322 words, 7 instructional graphics, and a text requiring a 6th grade reading ability with the equivalent 1991 CDC vaccine information pamphlet comprising 16 pages, 18,117 words, no graphics, and a text requiring a 10th grade reading level. We measured the reading ability of 522 parents of pediatric patients from northwest Louisiana seen at public clinics (81%) and in a private office (19%). Of the entire group, 39% were white, 60% African-American, and 1% Hispanic; the mean age was 29 years; the mean highest grade completed was 12th grade 3 months; and the reading level was less than 9th grade in 47% of parents and less than 7th grade in 20%. After parents were given one of the pamphlets to read, their reading time, comprehension, and attitude toward the pamphlet were measured.Results. Mean comprehension was 15% lower for CDC than for LSU (56% vs 72% correct; P < .001) and reading time was three times longer for CDC than for LSU (13 minutes 47 seconds vs 4 minutes 20 seconds; P < .0001). These trends were significant for parents reading at all but the lowest levels. Mean comprehension and reading time did not differ among parents reading at the third grade level or less. However, mean comprehension was greater and reading time lower for LSU among parents at all reading abilities greater than the third grade. Parents in the private practice setting took the longest time to read the CDC (20 minutes 59 seconds vs 5 minutes 46 seconds, LSU), yet their comprehension on the LSU was significantly higher than on the CDC (94% vs 71%; P < .0001). Two focus groups of high-income parents were unanimous in preferring the LSU.Conclusions. A short, simply written pamphlet with instructional graphics was preferred by high- and low-income parents seen in private and public clinics. The sixth grade reading level appears to be too high for many parents in public clinics; new materials aimed at third to fourth grade levels may be required. The new 1994 CDC immunization materials, written at the eighth grade level, may still be inappropriately high. The American medical community should adopt available techniques for the development of more effective patient-parent education materials.

Patients who misunderstand their diagnosis and treatment plans usually exhibit poor compliance. The 90 million adult Americans with low literacy skills struggle to understand such essential health information as discharge instructions, consent forms, oral instructions and drug labels. The Joint Commission on Accreditation of Health Organizations (JCAHO) now requires that instructions be given on a level understandable to the patient. Most physicians tend to give too much information on too high a level for many patients to understand. Physicians who speak in simpler language, repeat their instructions and demonstrate key points, while avoiding too many directives, enhance their patients' understanding. Combining easy-to-read written patient education materials with oral instructions has been shown to greatly enhance patient understanding. To be effective with patients whose literacy skills are low, patient education materials should be short and simple, contain culturally sensitive graphics and encourage desired behavior. Compliance with therapy also may be improved by including family members in the patient education process.

BACKGROUND. Low-income women utilize screening mammography less frequently, present at more advanced stages of disease, and have higher breast cancer mortality rates than women with higher incomes. The purpose of this study was to examine the relationship of reading ability to the knowledge and attitudes that low-income women have regarding screening mammography.METHODS. A convenience sample of 445 women were interviewed for this study. These women, age 40 years and older, had not had a mammogram in the past year, They were waiting to see a doctor in one of two outpatient clinics at Louisiana State University Medical Center in Shreveport when they were interviewed. A structured questionnaire assessed mammography knowledge and attitudes. Each patient's reading ability was assessed with the Rapid Estimate of Adult Literacy in Medicine (REALM).RESULTS. The women interviewed had a mean age of 56 years. Sixty-nine percent were African American, and 97% lived in households with annual incomes of less than $20,000. On the average, the highest grade completed in school was tenth grade. The average reading level was fourth ro sixth grade, with 76% reading below a 9th-grade level. Lower reading ability correlated significantly with less mammography knowledge (P < 0.0001). A tack of accurate information about mammography was prevalent among low-level readers. Thirty-nine percent of women reading at or below a third-grade level did not know why women are given mammograms, compared with 12% of those reading at or above a ninth-grade level. Cost was a great concern in general, but cost concerns did not vary by reading level; 41% of all participants were very concerned about cost.CONCLUSIONS. Limited literacy skills and lack of knowledge about screening mammography may contribute considerably to the underutilization of screening mammograms in few-income women. Screening for reading level may identify a subset of low-income patients who could benefit from specialized education. These results could help guide effective educational interventions and better provider-patient communication about screening mammography for low-literate, low-income women. (C) 1996 American Cancer Society.

To participate effectively in their health care, older patients often are expected to read a wide variety of materials, including written instructions, brochures, and consent forms. This study quantitates the reading ability of older patients and compares it to that of younger patients. Two hundred seventy-two patients 30 and older were selected from five outpatient clinics at a public teaching hospital and tested for objective reading ability using the Peabody Individual Achievement Test—Revised. The 76 patients 60 and older read significantly worse (grade level 2.9) than the 196 patients younger than 60 (grade level 5.8) (P<0.0001). Older patients also completed significantly fewer years of school than younger patients (7.3years versus 10.6years). Analysis of variance for age categories 30–44, 45–59, 60–74, and 75 and older confirmed declining reading ability and educational status with advancing age. Multiple regression analysis helped show that an equation could be derived to predict reading ability from age, educational status, race, and sex, but the coefficient of determination was so low (r2=0.39) that it cannot be considered clinically useful for individual patients. In this study, older patients read significantly worse than younger patients, and a formula that combines age, race, sex, and educational status cannot reliably predict reading ability for individual patients. Most older patients read on a level so low that they cannot be expected to read most commonly used written materials. Routine testing of reading ability may allow more appropriate design and use of written materials.

Adult inpatients in state-supported (public) and private substance misuse treatment settings were tested for reading ability. Patient education materials and consent forms were assessed for readability levels. Public patients' mean reading levels were significantly lower than those of private patients, and were 4 to 5 years below the level needed to read and understand standard treatment materials. More than half of the public and almost one-third of the private patients tested were reading below a 9th grade level. Standard treatment materials were written on 11th to 12th grade reading levels; admission and consent forms were written on 12th to 18th grade levels. Patients in substance misuse settings should be tested for literacy levels upon admission and provided with materials commensurate with their reading ability

Health care workers often assume that patients who have completed a certain grade in school can read at that level. This study examines the relationships between patient reading ability, the last grade completed, and the reading ability necessary to comprehend commonly used written materials. We tested 528 patients during regular visits to seven outpatient clinics serving a predominantly indigent population. In addition, we analyzed the readability of 280 brochures and consent forms used in these clinics. Most patients had reading abilities on a level far below their last grade completed, while almost all materials tested were written on a level far above average patient reading ability. We conclude that patient reading ability should be routinely tested and that written materials should be developed on a level commensurate with patient reading ability.

Esophageal perforation is a rare but catastrophic complication of nasogastric intubation. Diagnosis is frequently delayed, resulting in high mortality. We report a case of perforation due to nasogastric intubation in an otherwise normal esophagus. Patients at high risk of this complication can be identified, and special techniques can be used to avoid perforation. Percutaneous endoscopic gastrostomy is an alternative to nasogastric intubation for long-term enteral feeding. When nasogastric intubation is performed, clinical tests of tube position are not sufficient to guarantee proper tube position. The tip of the tube must be visualized radiographically in the stomach prior to initiation of tube feeding. When perforation does occur, proper management is often controversial. Therapy must be tailored to each individual case for the best possible outcome.