A randomized trial of pictorial versus prose-based medication information pamphlets Andrew E. Thompson a, *, Mark A. Goldszmidt a , Alan J. Schwartz b , Philip G. Bashook b a Department of Medicine, University of Western Ontario, London, Canada b Department of Medical Education, College of Medicine, University of Illinois at Chicago, Chicago, USA 1. Introduction Medication error, which can be a result of intentional or non- intentional factors [1], is frequent and can be associated with significant medical harm [2]. Therefore, accurate communication of information is important to prevent mistakes and improve adherence. Mistakes can occur when a patient does not fully understand a medication, its side effects, things to avoid, or reasons to seek medical help. An example might be the patient who drinks alcohol while taking a medication but does not know or remember that alcohol should be avoided. Information about medications is most commonly communi- cated verbally. However, only 14% of spoken instructions are remembered [3]; moreover, our memory for episodic and unstructured information such as test results and medical advice tends to diminish as we age [4]. As a solution, written prose-based pamphlets and information provided via the internet are used to supplement and enhance medication information. However, for written patient-oriented medication information to be of value, it must be comprehensible by the majority of the population. The problem is much of the available information is simply too complicated. It is complicated because: (a) it is created by paraphrasing product monographs which are written for health professionals; (b) it is written by individuals with no knowledge of the medication; (c) it contains too much information diluting important details; (d) it is not formatted properly; and (e) it is difficult to read and understand [5]. This problem is further exacerbated in low-literacy populations such as those who have not yet completed high school, immigrants, and the elderly [6]. A recent review of internet based medication information, for the medication methotrexate, found the average reading level of the information at grade 10 with a range from 7.2 to a maximum of 12 [7]. In contrast, the 2003 International Adult Literacy and Skills Survey (IALSS) found that 40% of the population does not possess a prose-literacy level suitable for the demands of a complex and advanced society [6]. Approximately one third of English speaking American adults have ‘‘inadequate or marginal health literacy’’ [8] and one third of English speaking American adults do not properly understand the medical and pharmaceutical information given to Patient Education and Counseling 78 (2010) 389–393 ARTICLE INFO Article history: Received 19 August 2009 Received in revised form 17 January 2010 Accepted 18 January 2010 Keywords: Patient information Health information Pamphlets ABSTRACT Objective: The goal of this study was to compare prose and pictorial-based information pamphlets about the medication methotrexate in the domains of free recall, cued recall, comprehension and utility. Methods: A single blind, randomized trial of picture versus prose-based information pamphlets including 100 participants aged 18–65 years of age, who had not completed high school, could read English, and had no prior knowledge about methotrexate. Superiority of pamphlet type was assessed using immediate free recall, cued recall and comprehension. Results: There were no differences between picture and prose pamphlets in free recall, cued recall, and comprehension either immediately or after a 1-week interval. Immediate free recall of important information was 17–26%; free recall fell even lower to 7–16% after 1 week. The pictorial pamphlet was preferred over the prose-based pamphlet. Conclusion: This study found no benefit in free recall, cued recall, or comprehension through the addition of pictograms to a simple prose-based medication pamphlet. Practice implications: In order for them to be effective in clinical practice, even simple medication information pamphlets that have been assessed for patients’ ability to comprehend them cannot be used as the sole means for conveying important medication-related information to patients. ß 2010 Elsevier Ireland Ltd. All rights reserved. * Corresponding author at: Rheumatology Centre, St. Joseph’s Health Care, 268 Grosvenor Street, P.O. Box 5777, London, ON, N6A 4V2 Canada. Tel.: +1 519 646 6337; fax: +1 519 646 6338. E-mail address: andy.thompson@rogers.com (A.E. Thompson). Contents lists available at ScienceDirect Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou 0738-3991/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2010.01.010