42191
JAG
Brief Report
Older Adults’ Views About “Managing Your Medications” Booklet
Journal of Applied Gerontology 32(3) 370–382 © The Author(s) 2011 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0733464811421910 jag.sagepub.com
Jill Robertson1, Karen B. Farris2, Susan K. Schultz3, Ryan M. Carnahan3, Brian Gryzlak3, and Elizabeth A. Chrischilles3 Abstract The objectives were to evaluate Managing Your Medications (MYM) booklet to improve medication management. Mailed packets, including MYM booklet and 4-page survey assessing comprehensibility, communicative effectiveness, and usefulness, were sent to a random sample of 250 older adults. The survey included perceptions of booklet, how to disseminate, and respondent’s health history. Descriptive statistics were used, and individuals were stratified by number of prescription medications and whether they reported side effects. A 59.6% response rate was obtained. The readability was Grade 8. Older adults reported it was comprehensible and 17% reported behavioral intentions to change their current actions regarding medications. Overall, 12.7% of respondents agreed that MYM changed their opinion of the topic. The most popular means to disseminate were doctors’ offices and senior citizens’ centers. Most older adults indicated the MYM booklet was readable, comprehensible, and would generate some behavior change regarding medication management. Keywords older adults, medication management, communication effectiveness Manuscript received: February 22, 2011; final revision received: August 3, 2011; accepted: August 8, 2011. 1
The Nebraska Medical Center in Omaha, NE, USA University of Michigan, Ann Arbor, MI, USA 3 The University of Iowa, Iowa City, IA, USA 2
Corresponding Author: Karen B. Farris, University of Michigan, 428 Church St, Ann Arbor, MI 48109, USA. Email: [email protected]
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Introduction Age-related changes including cognitive deficits, physical limitations such as inability to drive or use the telephone as well as complexity of medication regimens can make different aspects of medication management problematic for older adults. Whether living independently or in assisted living, medication management can be problematic for community-dwelling older adults (Kemp, Luo, & Ball, 2010). Web sites and brochures exist to assist individuals with asking questions about their medicines or keeping a medication list (Agency for Health care Research and Quality, 2003; National Council on Patient Information and Education, 2001, 2002; American Association of Retired Persons, 2011). Often, these tools are developed by professionals and are not well-tested with older adults. As well, patients may be unaware of the resources available to help manage their medications (Lakey, Gray, & Borson, 2009; Taira, 1991). The need for such tools is evident in the literature. Patients’ knowledge of medication tools was assessed among 109 independently living older adults at a continuing care retirement community in the state of Washington, of whom most were well educated, White, and female. Almost two thirds (62%) were using a self-filled pill box/organizer (Lakey, Gray, & Borson, 2009). Most participants (72% to 92%, depending on type of device) did not know about programmable medication organizers such as countertop automatic pill dispensers or pill boxes with timers and alarms. As well, over half of participants did not know about strategies to simplify regimens or medication packaging alternatives. Older adults are not aware of all the medication management tools available. There are web sites that provide patients with up-to-date information on tools to help manage their medications. The Agency for Health care Research and Quality provides information on “How to play it safe with medicines” (Agency for Health care Research and Quality, 2003). The National Council on Patient Information and Education (NCPIE) web sites provide information for consumers to make “sound decisions” when it comes to use of their medications (National Council on Patient Information and Education, 2001, 2002). Their goal is “to provide helpful information that supports consumers’ safe medicine use.” The AARP, a nonprofit, nonpartisan organization of individuals age 50 and above, also has several tools on their web site including Drugs A-Z, Drug Compare, Pill Identification, Drug Interaction Checker, and Symptom Checker (American Association of Retired Persons, 2011). However, the exact ways in which these tools are used are not known and their impact is unclear. Garner proposes that patient information leaflets be evaluated using three criteria including readability, comprehensibility, and communicative effectiveness (Garner, 2010; Hemy, 2011). Readability represents the ease that a reader can assign meaning to the
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words or text. Visually, this includes spacing, font size, color and graphics. Linguistically, consideration of readability ratings such as those in common word processing packages can be used. Comprehensibility may be assessed using knowledge questions such as a multiple-choice exam. Finally, communicative effectiveness may include intention to respond to behavioral messages. The Collaborative Medication Management booklet was part of an intervention study, and the goal of the CDC-sponsored project was to examine whether the Collaborative Medication Management intervention along with Living Well with a Disability was superior to Living Well with a Disability alone and control group in reducing symptoms such as rash, dizziness, breathing difficulties, and pain (Chrischilles & Lindgren, 2006). The 25-page Collaborative Medication Management booklet was vetted through a series of meetings involving clients with disabilities, health care providers and pharmacy specialists. For this study, three primary changes were made including (a) language in Manage Your Medications (MYM) booklet was changed for general use with broad dissemination to older adults, (b) some examples of conversations with pharmacy staff and discussion about experiencing an adverse drug event were removed for brevity, and (c) Medicare Part D and Medication Therapy Management (MTM) were explained versus collaborative medication management. The objective of this study was to evaluate the MYM as a tool to improve medication management among older adults in terms of its readability, comprehensibility, and communicative effectiveness.
Method Data sources. A mailed packet including the Manage Your Medications booklet and survey with no follow-up was conducted using a registry of individuals 50 years and older. A random sample of 250 individuals from The University of Iowa Center on Aging Seniors Together in Aging Registry (STAR) was used (The University of Iowa Center on Aging, 2007). A drawing for one of four US$25.00 grocery gift certificates was included. Booklet. The MYM booklet was 24 pages and structured in nine topics (Figure 1, for example). It provided information on how individuals can take control of their medications and highlighted knowing key questions to ask about medications, going to one pharmacy, keeping an up-to-date medication list, taking medications regularly, how to recognize and report an adverse drug event. A copy of MYM is available at http://www.public-health.uiowa.edu/cert/education/ManagingYour Meds.pdf. Data collection. For readability, indicators from MS Word were used including Flesch Reading Ease and Flesch-Kincaid Grade Level. As well, quantification of
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Figure 1. Examples from Manage Your Medications booklet.
the text in words/sentence was done. For readability, perceptions of presentation including formatting and annoyances were also obtained. For comprehensibility, older adults’ perceptions of their ability to understand the booklet, ability to explain it to others, whether it was unclear or difficult, and if it was too technical
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or too basic was determined. For communicative effectiveness, respondents indicated if their opinion about the topic changed and their intention to change their current actions based on the booklet. They also indicated if they thought the content may change other’s behavior and it if changed their own opinions. Survey items were investigator generated and the responses used 5-point rating scales (strongly disagree to strongly agree). Other items such as how to best disseminate MYM used check all that apply or fill in the blank. There was an opportunity for respondents to provide free-text comments. The survey also asked about the respondent’s health history including medication use, ability to manage medications, and whether respondents regularly saw a family doctor, physician assistant, or nurse practitioner. Analysis. Descriptive statistics were used to analyze the data. Differences in percent agreement (strongly agree and agree versus disagree and strongly disagree) were examined by stratifying respondents by the number of prescription medications they took (0-1, 2-4, and ≥5) and whether they reported any problems in the past with medication side effects. The association of Manage Your Medication booklet perceptions with number of prescription medications and past side effects was examined using chi-square tests.
Results There was a 59.6% response rate with 149 completed surveys. The average number of prescription medications taken was 2.93 (SD = 2.89), and 50% took between 2 and 4 prescription medications. One or less prescription medication was the next most common at 37%, and 13% took 5 or more prescription medications. For nonprescription medicines, 11% used none, 55% used 1 to 3 and 34% used 4 or more (range 0 to 10). The number of participants who went to one pharmacy was 79%. Most respondents (92%) were able to independently take the correct medication and proper dosage at the correct times. The average number of physicians the participants saw was 2.15 (SD = 1.24). About 93% regularly saw a family physician, physician assistant, or nurse practitioner. Just above one quarter (27%) reported having problems with medication side effects in the past. In terms of readability, the Flesch Reading Ease was 60% and the FleschKincaid Grade Level was 8.0. On average, there were 12.8 words per sentence and 4.8 characters per word. Two thirds of respondents indicated the booklet was presented in an interesting way (Table 1). Formatting and lettering were acceptable to more than 75% and less than 15% indicated that some section was annoying or made them feel uncomfortable. Regarding comprehensibility, almost 95% of respondents said the booklet was easy to understand and they could explain it to others. Just above 20% thought it was too basic. For communicative effectiveness,
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Robertson et al. Table 1. Older Adults’ Ratings of Readability, Comprehensibility, and Communicative Effectiveness of the Manage Your Medications Booklet.
Percentage that agreed or strongly agreed (%) Readability Presented in an interesting way (n = 149) Format, lettering, pictures appropriate (n = 145) Sections were annoying or made me feel uncomfortable (n = 145) Comprehensibility Easy to understand (n = 148) Could explain to others (n = 149) Too technical (n = 149) Too basic (n = 149) Unclear or difficult (n = 145) Communicative effectiveness—after reading the MYM booklet, it . . . Changed my opinion of the topic (n = 149) Will change my current actions (n = 149) May help others change their health practices (n = 149)
64.4 76.5 13.8
94.6 94.6 2.7 22.2 13.1 12.7 17.4 78.6
13% indicated they changed their opinion of the medication management and 17% indicated intentions to change their own behavior. Most respondents found the MYM booklet useful, particularly for older adults (Table 2). The majority would recommend the booklet to other older adults. When respondents’ responses were evaluated based on the number of prescription medications they took, statistically significant differences were found for three items, compared to the overall findings (Table 1). Overall, 12.7% of respondents agreed that MYM changed their opinion of the topic. However, 22% of individuals taking 0 to 1 prescription medications, 5.1% of individuals taking 2 to 4 medications, and 11.8% of respondents’ taking ≥5 medications agreed that the booklet changed their opinion of the topic (χ2 = 6.1, 2df, p = .046). A higher number of prescription medications were also associated with higher percent agreement that the booklet was prepared in an interesting way (χ2 = 7.5, 2df, p = .024). Those using a higher number of prescription medications also had a higher percent agreement that formatting, lettering, and appropriate pictures were used (χ2 = 10.1, 2df, p = .006). Finally, 90% of individuals reporting problems with medication side effects in the past agreed the booklet may help others change their health practices, while only 75% of individuals reporting no problems with medication side effects in the past agreed (χ2 = 4.2, 2df, p = .041).
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Table 2. Older Adults’ Perception of Usefulness of Manage Your Medications Booklet. Percentage that agreed or strongly agreed (%) The MYM booklet is/maybe useful for Me (n = 147) Older adults (n = 149) People with many medical problems (n = 149) Anyone (n = 149) I would recommend to other older adults (n = 146) The MYM booklet made me Interested in learning more (n = 149) More aware of all things I can do to manage medications (n = 149)
81.7 93.9 51.0 84.5 80.1 42.3 61.8
Respondents were asked to list the characteristics of people who they thought would most benefit from the information using free text, and these data were categorized. Older adults with multiple medications, such as “daily medications,” “more than 1 or 2,” “many meds,” or up to “10-20 pill bottles on kitchen counter” were thought to be able to benefit from the MYM booklet (n = 58 written responses). Thirty-six of the respondents thought people with limited knowledge about their medications, those with a learning disability, or those receiving their first prescription would benefit. Five of the respondents would recommend it to anybody taking prescription medications. The most popular means to disseminate the MYM booklet were doctors’ offices and senior citizens’ centers (Figures 2 and 3). Technology as a means to disseminate the booklet was not as highly recommended as public places or from family and friends. Regarding “other” places to distribute the booklet, community pharmacies where medications are obtained was a common response.
Discussion Overall, the findings suggest that the booklet is useful, but its effectiveness should be improved so that more behavior changes result. The framework used to evaluate the MYM booklet is typically focused on patient information leaflets (Garner, 2010). This booklet differs from leaflets in that there are numerous topics and suggested behaviors in the booklet, whereas patient information leaflets may be focused on one disease/condition or medication. The assessment of com-
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100 90 80
Percent
70 60 50 40 30 20 10 0
Public library
Senior Women’s Men’s cizens’ groups groups center
Support groups
Book clubs
Garden Church clubs acvies
Figure 2. Public locations where older adults agreed that Manage Your Medications could be disseminated (n = 147).
100 90 80
Percent
70 60 50 40 30 20 10 0
Figure 3. Media and personal dissemination of Manage Your Medications (n = 149).
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prehensibility in this study was not with a multiple-choice questionnaire or knowledge survey and that should be undertaken prior to widespread use. Among the respondents, individuals who took zero to one medication or those taking greater than five medications were more likely to report that their opinion of the topic changed than individuals taking two to four medications. It may be that individuals with zero to one medication may not be aware of the complexity of managing multiple medications and they valued the information because it raised their awareness of possible issues that may arise in the future. Those individuals managing greater than five medications may feel overwhelmed such that the booklet was helpful with understanding management techniques. The MYM booklet appears that it can provide older adults with valuable information on managing their medications, and it may improve the knowledge of older adults and help them consider a variety of strategies beyond self-filled pill boxes (Lakey, Gray, & Borson, 2009). Consistent with the theory of planned behavior, respondents reported their behavioral intention changed by reading MYM, and this is important because changing knowledge and attitudes and reducing barriers (via knowledge of examples in MYM) may provide older adults with medication management strategies, or new behaviors, they had not previously considered (Montano & Kasprzyk, 2008). The percentage of the respondents who found the booklet to be prepared in an interesting way, with the format, lettering, and pictures believed to be appropriate, increased as the number of medications they were taking increased. This finding is consistent with models of persuasion, wherein “motivated” individuals process the information that is most relevant to them (Petty, Barden, & Wheeler, 2002). For example, individuals taking a higher number of medications may be more motivated to review the booklet fully and endorse it as helpful because of its relevance to them personally. The study asked about ways to disseminate the MYM booklet. Doctors’ offices and senior citizens’ centers were among the venues identified for providing the MYM booklet, along with public libraries and pharmacies where medications are obtained. While there are medication management tools on the Internet, older adults did not endorse the Internet and other technology as primary ways to disseminate the MYM booklet. This is in contrast to a survey of 100 elderly volunteers from senior centers and independent living buildings where 58% reported they would use an electronic memory aid. However, the aid would be its own presumably easy-to-use device and would not require a computer to access it (Cohen-Mansfield et al., 2005). Importantly, they indicated that monitoring medications had the highest importance ratings among the possible functions of a memory device. What is important is that technology must be partnered with personal strategies. In fact, technology or personal strategies using social
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networks and key opinion leaders may be a fruitful avenue for dissemination (Rogers, 2003). Alternatively, homecare providers may be important partners in future work, as they reach a vulnerable population that may benefit from additional medication management strategies but who do not visit senior centers or pharmacies. It is important to continue to reach out to older adults and fill the gap of the lack of knowledge on medication management strategies. Future work with the MYM booklet will include its revision into a shorter print-based booklet with additional readability and comprehensibility testing with older adults. The target population should be individuals who use 5 more medications for at least 2 chronic conditions, as this group may be more representative of individuals who have medication management difficulties. Following this testing, communication effectiveness can be established using a follow-up study, asking participants to review/use the booklet with follow-up in 30 and 90 days to determine specific behaviors or behavior changes mentioned in the booklet. The booklet can be available electronically wherein additional links may be built into the document, rather than a PDF of the print-based version. It is conceivable that a “quiz” could be developed based on the principles in the MYM and used as a self-administered screening device. Certainly, these types of tips about medication management could be incorporated into an electronic personal health record via emails or links. After additional testing, an organization like AARP may be approached for dissemination as well. The current study used a random sample from a registry of older adults, which is a volunteer research registry and may not be representative of the broader older adult population. In fact, respondents used few prescriptions medications. Most of the participants went to one pharmacy and the majority reported that they were able to independently take the correct medication and proper dosage at the correct times. Therefore, the respondents in the study cannot be extrapolated to older adults who may have poorer health, greater limitations, and/or numbers of medications. These results will be used to modify aspects of the MYM booklet. In fact, consideration has been given to a more in-depth and detailed booklet, given that 22% indicated it was too simple. It is critical that information be available for individuals with lower literacy, but older adults seeking more advanced information may also be accommodated. Future studies should consider shortening the booklet, making it more compact, using versions with different information, and investing in professional graphics and production.
Conclusion Most older adults indicated that the Manage Your Medications booklet was readable, comprehensible, and would generate some behavior change regarding medi-
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cation management. Dissemination via senior citizen centers and physicians was most commonly endorsed and electronic means were not highly recommended.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The project was supported in part by Centers for Disease Control grant number R01 DD000107. It built on infrastructure provided by an Agency for Healthcare Research and Quality (AHRQ) Centers for Education and Research on Therapeutics cooperative agreement #5 U18 HSO16094. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.
References Agency for Healthcare Research and Quality. (2003). Your medicine: Play it safe. Patient Guide. Retrieved from http://www.ahrq.gov/consumer/safemeds/safemeds .htm American Association of Retired Persons. AARP Health—Health Tools. Retrieved September 1, 2011, from http://www.aarp.org/health/health_tools/ Chrischilles, E. A., & Lindgren, S. D. (2006). Pharmaceutical case management and living well with a disability. Atlanta, GA: U.S. Department of Health & Human Services, Centers for Disease Control & Prevention. Cohen-Mansfield, J., Creedon, M. A., Malone, T. B., Kirkpatrick, M. J., Dutra, L., & Herman, R. P. (2005). Electronic memory aids for community-dwelling elderly persons: Attitudes, preferences and potential utilization. Journal of Applied Gerontology, 24, 3-20. Garner, M. (2010). Communication research and pharmacy practice: Inaugural meeting of an international special interest group. 16th International Social Pharmacy Workshop. Pharmacy Practice, 8(Suppl. 1), 1-136. Hemy, K. (2011). An investigation into the communicative effectiveness of patient information leaflets. University of Aberdeen, Aberdeen Scotland. Kemp, C. L., Luo, S., & Ball, M. M. (2010, September 13). Meds are a real tricky area: Examining medication management and regulation in assisted living. Journal of Applied Gerontology. doi: 10.1177/0733464810381986 Lakey, S. L., Gray, S. L., & Borson, S. (2009). Assessment of older adults’ knowledge of and preferences for medication management tools and support systems. Annals of Pharmacotherapy, 43, 1011-1019.
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Montano, D. E., & Kasprzyk, D. (2008). Theory of reasoned action, theory of planned behavior and the integrated behavioral model. In K. Glanz, P. K. Rimer, & K. Viswanath (Eds.), Health behavior and health education (pp. 267-296). San Francisco, CA: Jossey-Bass. National Council on Patient Information and Education. (2001). Educate before you medicate. Retrieved from http://www.talkaboutrx.org/index.jsp National Council on Patient Information and Education. (2002). Be MedWise. Retrieved from http://www.bemedwise.org/know_meds/know_meds.htm Petty, R. E., Barden, J., & Wheeler, S. C. (2002). The elaboration likelihood model of persuasion: Health promotions that yield sustained behavior change. In R. J. DiClemente, R. A. Crosby, M. C. Kegler (Eds.), Emerging theories in health promotion practice and research (pp. 71-99). San Francisco, CA: Jossey-Bass. Rogers, D. M. (2003). Diffusion of innovations (5th ed.). New York, NY: Simon & Schuster. Taira, F. (1991). Teaching independently living older adults about managing their medications. Rehabilitation Nursing, 16, 322-326. The University of Iowa Center on Aging. (2007). STAR registry: Seniors together in aging research. Retrieved from http://www.centeronaging.uiowa.edu/New_VolunteerRegistry/STAR_investigators.shtml
Author Biographies Jill Robertson, PharmD, is a PGY2 oncology pharmacy resident at The Nebraska Medical Center in Omaha, Nebraska. Karen B. Farris, PhD, is Charles R. Walgreen III professor in pharmacy administration, University of Michigan College of Pharmacy. Her research examines how older adults manage their medications and the roles of community and ambulatory pharmacists in influencing medication use, including public health issues. Susan K. Schultz, MD, is professor in the Department of Psychiatry at The University of Iowa Carver College of Medicine. Her research interests include the care and treatment of patients in late life who suffer from dementia such as Alzheimer’s disease. Ryan M. Carnahan, PharmD, MS, is clinical assistant professor in the Department of Epidemiology at The University of Iowa College of Public Health. His research interests include the pharmacoepidemiology of psychiatric medications and medication side effects, particularly among older adults.
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Brian Gryzlak, MA, MSW, is research specialist in the Department of Epidemiology at The University of Iowa College of Public Health. He coordinates several studies on emergent strategies to optimize appropriate medication use, primarily among older adults. Elizabeth A. Chrischilles, PhD, is professor and Marvin A. and Rose Lee Pomerantz chair in public health in the Department of Epidemiology at The University of Iowa College of Public Health. Her research uses health services epidemiology and health care effectiveness strategies to examine cancer outcomes in practice and medication use and effects among older adults.
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JAG
Brief Report
Older Adults’ Views About “Managing Your Medications” Booklet
Journal of Applied Gerontology 32(3) 370–382 © The Author(s) 2011 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0733464811421910 jag.sagepub.com
Jill Robertson1, Karen B. Farris2, Susan K. Schultz3, Ryan M. Carnahan3, Brian Gryzlak3, and Elizabeth A. Chrischilles3 Abstract The objectives were to evaluate Managing Your Medications (MYM) booklet to improve medication management. Mailed packets, including MYM booklet and 4-page survey assessing comprehensibility, communicative effectiveness, and usefulness, were sent to a random sample of 250 older adults. The survey included perceptions of booklet, how to disseminate, and respondent’s health history. Descriptive statistics were used, and individuals were stratified by number of prescription medications and whether they reported side effects. A 59.6% response rate was obtained. The readability was Grade 8. Older adults reported it was comprehensible and 17% reported behavioral intentions to change their current actions regarding medications. Overall, 12.7% of respondents agreed that MYM changed their opinion of the topic. The most popular means to disseminate were doctors’ offices and senior citizens’ centers. Most older adults indicated the MYM booklet was readable, comprehensible, and would generate some behavior change regarding medication management. Keywords older adults, medication management, communication effectiveness Manuscript received: February 22, 2011; final revision received: August 3, 2011; accepted: August 8, 2011. 1
The Nebraska Medical Center in Omaha, NE, USA University of Michigan, Ann Arbor, MI, USA 3 The University of Iowa, Iowa City, IA, USA 2
Corresponding Author: Karen B. Farris, University of Michigan, 428 Church St, Ann Arbor, MI 48109, USA. Email: [email protected]
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Introduction Age-related changes including cognitive deficits, physical limitations such as inability to drive or use the telephone as well as complexity of medication regimens can make different aspects of medication management problematic for older adults. Whether living independently or in assisted living, medication management can be problematic for community-dwelling older adults (Kemp, Luo, & Ball, 2010). Web sites and brochures exist to assist individuals with asking questions about their medicines or keeping a medication list (Agency for Health care Research and Quality, 2003; National Council on Patient Information and Education, 2001, 2002; American Association of Retired Persons, 2011). Often, these tools are developed by professionals and are not well-tested with older adults. As well, patients may be unaware of the resources available to help manage their medications (Lakey, Gray, & Borson, 2009; Taira, 1991). The need for such tools is evident in the literature. Patients’ knowledge of medication tools was assessed among 109 independently living older adults at a continuing care retirement community in the state of Washington, of whom most were well educated, White, and female. Almost two thirds (62%) were using a self-filled pill box/organizer (Lakey, Gray, & Borson, 2009). Most participants (72% to 92%, depending on type of device) did not know about programmable medication organizers such as countertop automatic pill dispensers or pill boxes with timers and alarms. As well, over half of participants did not know about strategies to simplify regimens or medication packaging alternatives. Older adults are not aware of all the medication management tools available. There are web sites that provide patients with up-to-date information on tools to help manage their medications. The Agency for Health care Research and Quality provides information on “How to play it safe with medicines” (Agency for Health care Research and Quality, 2003). The National Council on Patient Information and Education (NCPIE) web sites provide information for consumers to make “sound decisions” when it comes to use of their medications (National Council on Patient Information and Education, 2001, 2002). Their goal is “to provide helpful information that supports consumers’ safe medicine use.” The AARP, a nonprofit, nonpartisan organization of individuals age 50 and above, also has several tools on their web site including Drugs A-Z, Drug Compare, Pill Identification, Drug Interaction Checker, and Symptom Checker (American Association of Retired Persons, 2011). However, the exact ways in which these tools are used are not known and their impact is unclear. Garner proposes that patient information leaflets be evaluated using three criteria including readability, comprehensibility, and communicative effectiveness (Garner, 2010; Hemy, 2011). Readability represents the ease that a reader can assign meaning to the
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words or text. Visually, this includes spacing, font size, color and graphics. Linguistically, consideration of readability ratings such as those in common word processing packages can be used. Comprehensibility may be assessed using knowledge questions such as a multiple-choice exam. Finally, communicative effectiveness may include intention to respond to behavioral messages. The Collaborative Medication Management booklet was part of an intervention study, and the goal of the CDC-sponsored project was to examine whether the Collaborative Medication Management intervention along with Living Well with a Disability was superior to Living Well with a Disability alone and control group in reducing symptoms such as rash, dizziness, breathing difficulties, and pain (Chrischilles & Lindgren, 2006). The 25-page Collaborative Medication Management booklet was vetted through a series of meetings involving clients with disabilities, health care providers and pharmacy specialists. For this study, three primary changes were made including (a) language in Manage Your Medications (MYM) booklet was changed for general use with broad dissemination to older adults, (b) some examples of conversations with pharmacy staff and discussion about experiencing an adverse drug event were removed for brevity, and (c) Medicare Part D and Medication Therapy Management (MTM) were explained versus collaborative medication management. The objective of this study was to evaluate the MYM as a tool to improve medication management among older adults in terms of its readability, comprehensibility, and communicative effectiveness.
Method Data sources. A mailed packet including the Manage Your Medications booklet and survey with no follow-up was conducted using a registry of individuals 50 years and older. A random sample of 250 individuals from The University of Iowa Center on Aging Seniors Together in Aging Registry (STAR) was used (The University of Iowa Center on Aging, 2007). A drawing for one of four US$25.00 grocery gift certificates was included. Booklet. The MYM booklet was 24 pages and structured in nine topics (Figure 1, for example). It provided information on how individuals can take control of their medications and highlighted knowing key questions to ask about medications, going to one pharmacy, keeping an up-to-date medication list, taking medications regularly, how to recognize and report an adverse drug event. A copy of MYM is available at http://www.public-health.uiowa.edu/cert/education/ManagingYour Meds.pdf. Data collection. For readability, indicators from MS Word were used including Flesch Reading Ease and Flesch-Kincaid Grade Level. As well, quantification of
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Figure 1. Examples from Manage Your Medications booklet.
the text in words/sentence was done. For readability, perceptions of presentation including formatting and annoyances were also obtained. For comprehensibility, older adults’ perceptions of their ability to understand the booklet, ability to explain it to others, whether it was unclear or difficult, and if it was too technical
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or too basic was determined. For communicative effectiveness, respondents indicated if their opinion about the topic changed and their intention to change their current actions based on the booklet. They also indicated if they thought the content may change other’s behavior and it if changed their own opinions. Survey items were investigator generated and the responses used 5-point rating scales (strongly disagree to strongly agree). Other items such as how to best disseminate MYM used check all that apply or fill in the blank. There was an opportunity for respondents to provide free-text comments. The survey also asked about the respondent’s health history including medication use, ability to manage medications, and whether respondents regularly saw a family doctor, physician assistant, or nurse practitioner. Analysis. Descriptive statistics were used to analyze the data. Differences in percent agreement (strongly agree and agree versus disagree and strongly disagree) were examined by stratifying respondents by the number of prescription medications they took (0-1, 2-4, and ≥5) and whether they reported any problems in the past with medication side effects. The association of Manage Your Medication booklet perceptions with number of prescription medications and past side effects was examined using chi-square tests.
Results There was a 59.6% response rate with 149 completed surveys. The average number of prescription medications taken was 2.93 (SD = 2.89), and 50% took between 2 and 4 prescription medications. One or less prescription medication was the next most common at 37%, and 13% took 5 or more prescription medications. For nonprescription medicines, 11% used none, 55% used 1 to 3 and 34% used 4 or more (range 0 to 10). The number of participants who went to one pharmacy was 79%. Most respondents (92%) were able to independently take the correct medication and proper dosage at the correct times. The average number of physicians the participants saw was 2.15 (SD = 1.24). About 93% regularly saw a family physician, physician assistant, or nurse practitioner. Just above one quarter (27%) reported having problems with medication side effects in the past. In terms of readability, the Flesch Reading Ease was 60% and the FleschKincaid Grade Level was 8.0. On average, there were 12.8 words per sentence and 4.8 characters per word. Two thirds of respondents indicated the booklet was presented in an interesting way (Table 1). Formatting and lettering were acceptable to more than 75% and less than 15% indicated that some section was annoying or made them feel uncomfortable. Regarding comprehensibility, almost 95% of respondents said the booklet was easy to understand and they could explain it to others. Just above 20% thought it was too basic. For communicative effectiveness,
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Robertson et al. Table 1. Older Adults’ Ratings of Readability, Comprehensibility, and Communicative Effectiveness of the Manage Your Medications Booklet.
Percentage that agreed or strongly agreed (%) Readability Presented in an interesting way (n = 149) Format, lettering, pictures appropriate (n = 145) Sections were annoying or made me feel uncomfortable (n = 145) Comprehensibility Easy to understand (n = 148) Could explain to others (n = 149) Too technical (n = 149) Too basic (n = 149) Unclear or difficult (n = 145) Communicative effectiveness—after reading the MYM booklet, it . . . Changed my opinion of the topic (n = 149) Will change my current actions (n = 149) May help others change their health practices (n = 149)
64.4 76.5 13.8
94.6 94.6 2.7 22.2 13.1 12.7 17.4 78.6
13% indicated they changed their opinion of the medication management and 17% indicated intentions to change their own behavior. Most respondents found the MYM booklet useful, particularly for older adults (Table 2). The majority would recommend the booklet to other older adults. When respondents’ responses were evaluated based on the number of prescription medications they took, statistically significant differences were found for three items, compared to the overall findings (Table 1). Overall, 12.7% of respondents agreed that MYM changed their opinion of the topic. However, 22% of individuals taking 0 to 1 prescription medications, 5.1% of individuals taking 2 to 4 medications, and 11.8% of respondents’ taking ≥5 medications agreed that the booklet changed their opinion of the topic (χ2 = 6.1, 2df, p = .046). A higher number of prescription medications were also associated with higher percent agreement that the booklet was prepared in an interesting way (χ2 = 7.5, 2df, p = .024). Those using a higher number of prescription medications also had a higher percent agreement that formatting, lettering, and appropriate pictures were used (χ2 = 10.1, 2df, p = .006). Finally, 90% of individuals reporting problems with medication side effects in the past agreed the booklet may help others change their health practices, while only 75% of individuals reporting no problems with medication side effects in the past agreed (χ2 = 4.2, 2df, p = .041).
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Table 2. Older Adults’ Perception of Usefulness of Manage Your Medications Booklet. Percentage that agreed or strongly agreed (%) The MYM booklet is/maybe useful for Me (n = 147) Older adults (n = 149) People with many medical problems (n = 149) Anyone (n = 149) I would recommend to other older adults (n = 146) The MYM booklet made me Interested in learning more (n = 149) More aware of all things I can do to manage medications (n = 149)
81.7 93.9 51.0 84.5 80.1 42.3 61.8
Respondents were asked to list the characteristics of people who they thought would most benefit from the information using free text, and these data were categorized. Older adults with multiple medications, such as “daily medications,” “more than 1 or 2,” “many meds,” or up to “10-20 pill bottles on kitchen counter” were thought to be able to benefit from the MYM booklet (n = 58 written responses). Thirty-six of the respondents thought people with limited knowledge about their medications, those with a learning disability, or those receiving their first prescription would benefit. Five of the respondents would recommend it to anybody taking prescription medications. The most popular means to disseminate the MYM booklet were doctors’ offices and senior citizens’ centers (Figures 2 and 3). Technology as a means to disseminate the booklet was not as highly recommended as public places or from family and friends. Regarding “other” places to distribute the booklet, community pharmacies where medications are obtained was a common response.
Discussion Overall, the findings suggest that the booklet is useful, but its effectiveness should be improved so that more behavior changes result. The framework used to evaluate the MYM booklet is typically focused on patient information leaflets (Garner, 2010). This booklet differs from leaflets in that there are numerous topics and suggested behaviors in the booklet, whereas patient information leaflets may be focused on one disease/condition or medication. The assessment of com-
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100 90 80
Percent
70 60 50 40 30 20 10 0
Public library
Senior Women’s Men’s cizens’ groups groups center
Support groups
Book clubs
Garden Church clubs acvies
Figure 2. Public locations where older adults agreed that Manage Your Medications could be disseminated (n = 147).
100 90 80
Percent
70 60 50 40 30 20 10 0
Figure 3. Media and personal dissemination of Manage Your Medications (n = 149).
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prehensibility in this study was not with a multiple-choice questionnaire or knowledge survey and that should be undertaken prior to widespread use. Among the respondents, individuals who took zero to one medication or those taking greater than five medications were more likely to report that their opinion of the topic changed than individuals taking two to four medications. It may be that individuals with zero to one medication may not be aware of the complexity of managing multiple medications and they valued the information because it raised their awareness of possible issues that may arise in the future. Those individuals managing greater than five medications may feel overwhelmed such that the booklet was helpful with understanding management techniques. The MYM booklet appears that it can provide older adults with valuable information on managing their medications, and it may improve the knowledge of older adults and help them consider a variety of strategies beyond self-filled pill boxes (Lakey, Gray, & Borson, 2009). Consistent with the theory of planned behavior, respondents reported their behavioral intention changed by reading MYM, and this is important because changing knowledge and attitudes and reducing barriers (via knowledge of examples in MYM) may provide older adults with medication management strategies, or new behaviors, they had not previously considered (Montano & Kasprzyk, 2008). The percentage of the respondents who found the booklet to be prepared in an interesting way, with the format, lettering, and pictures believed to be appropriate, increased as the number of medications they were taking increased. This finding is consistent with models of persuasion, wherein “motivated” individuals process the information that is most relevant to them (Petty, Barden, & Wheeler, 2002). For example, individuals taking a higher number of medications may be more motivated to review the booklet fully and endorse it as helpful because of its relevance to them personally. The study asked about ways to disseminate the MYM booklet. Doctors’ offices and senior citizens’ centers were among the venues identified for providing the MYM booklet, along with public libraries and pharmacies where medications are obtained. While there are medication management tools on the Internet, older adults did not endorse the Internet and other technology as primary ways to disseminate the MYM booklet. This is in contrast to a survey of 100 elderly volunteers from senior centers and independent living buildings where 58% reported they would use an electronic memory aid. However, the aid would be its own presumably easy-to-use device and would not require a computer to access it (Cohen-Mansfield et al., 2005). Importantly, they indicated that monitoring medications had the highest importance ratings among the possible functions of a memory device. What is important is that technology must be partnered with personal strategies. In fact, technology or personal strategies using social
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networks and key opinion leaders may be a fruitful avenue for dissemination (Rogers, 2003). Alternatively, homecare providers may be important partners in future work, as they reach a vulnerable population that may benefit from additional medication management strategies but who do not visit senior centers or pharmacies. It is important to continue to reach out to older adults and fill the gap of the lack of knowledge on medication management strategies. Future work with the MYM booklet will include its revision into a shorter print-based booklet with additional readability and comprehensibility testing with older adults. The target population should be individuals who use 5 more medications for at least 2 chronic conditions, as this group may be more representative of individuals who have medication management difficulties. Following this testing, communication effectiveness can be established using a follow-up study, asking participants to review/use the booklet with follow-up in 30 and 90 days to determine specific behaviors or behavior changes mentioned in the booklet. The booklet can be available electronically wherein additional links may be built into the document, rather than a PDF of the print-based version. It is conceivable that a “quiz” could be developed based on the principles in the MYM and used as a self-administered screening device. Certainly, these types of tips about medication management could be incorporated into an electronic personal health record via emails or links. After additional testing, an organization like AARP may be approached for dissemination as well. The current study used a random sample from a registry of older adults, which is a volunteer research registry and may not be representative of the broader older adult population. In fact, respondents used few prescriptions medications. Most of the participants went to one pharmacy and the majority reported that they were able to independently take the correct medication and proper dosage at the correct times. Therefore, the respondents in the study cannot be extrapolated to older adults who may have poorer health, greater limitations, and/or numbers of medications. These results will be used to modify aspects of the MYM booklet. In fact, consideration has been given to a more in-depth and detailed booklet, given that 22% indicated it was too simple. It is critical that information be available for individuals with lower literacy, but older adults seeking more advanced information may also be accommodated. Future studies should consider shortening the booklet, making it more compact, using versions with different information, and investing in professional graphics and production.
Conclusion Most older adults indicated that the Manage Your Medications booklet was readable, comprehensible, and would generate some behavior change regarding medi-
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cation management. Dissemination via senior citizen centers and physicians was most commonly endorsed and electronic means were not highly recommended.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The project was supported in part by Centers for Disease Control grant number R01 DD000107. It built on infrastructure provided by an Agency for Healthcare Research and Quality (AHRQ) Centers for Education and Research on Therapeutics cooperative agreement #5 U18 HSO16094. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.
References Agency for Healthcare Research and Quality. (2003). Your medicine: Play it safe. Patient Guide. Retrieved from http://www.ahrq.gov/consumer/safemeds/safemeds .htm American Association of Retired Persons. AARP Health—Health Tools. Retrieved September 1, 2011, from http://www.aarp.org/health/health_tools/ Chrischilles, E. A., & Lindgren, S. D. (2006). Pharmaceutical case management and living well with a disability. Atlanta, GA: U.S. Department of Health & Human Services, Centers for Disease Control & Prevention. Cohen-Mansfield, J., Creedon, M. A., Malone, T. B., Kirkpatrick, M. J., Dutra, L., & Herman, R. P. (2005). Electronic memory aids for community-dwelling elderly persons: Attitudes, preferences and potential utilization. Journal of Applied Gerontology, 24, 3-20. Garner, M. (2010). Communication research and pharmacy practice: Inaugural meeting of an international special interest group. 16th International Social Pharmacy Workshop. Pharmacy Practice, 8(Suppl. 1), 1-136. Hemy, K. (2011). An investigation into the communicative effectiveness of patient information leaflets. University of Aberdeen, Aberdeen Scotland. Kemp, C. L., Luo, S., & Ball, M. M. (2010, September 13). Meds are a real tricky area: Examining medication management and regulation in assisted living. Journal of Applied Gerontology. doi: 10.1177/0733464810381986 Lakey, S. L., Gray, S. L., & Borson, S. (2009). Assessment of older adults’ knowledge of and preferences for medication management tools and support systems. Annals of Pharmacotherapy, 43, 1011-1019.
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Montano, D. E., & Kasprzyk, D. (2008). Theory of reasoned action, theory of planned behavior and the integrated behavioral model. In K. Glanz, P. K. Rimer, & K. Viswanath (Eds.), Health behavior and health education (pp. 267-296). San Francisco, CA: Jossey-Bass. National Council on Patient Information and Education. (2001). Educate before you medicate. Retrieved from http://www.talkaboutrx.org/index.jsp National Council on Patient Information and Education. (2002). Be MedWise. Retrieved from http://www.bemedwise.org/know_meds/know_meds.htm Petty, R. E., Barden, J., & Wheeler, S. C. (2002). The elaboration likelihood model of persuasion: Health promotions that yield sustained behavior change. In R. J. DiClemente, R. A. Crosby, M. C. Kegler (Eds.), Emerging theories in health promotion practice and research (pp. 71-99). San Francisco, CA: Jossey-Bass. Rogers, D. M. (2003). Diffusion of innovations (5th ed.). New York, NY: Simon & Schuster. Taira, F. (1991). Teaching independently living older adults about managing their medications. Rehabilitation Nursing, 16, 322-326. The University of Iowa Center on Aging. (2007). STAR registry: Seniors together in aging research. Retrieved from http://www.centeronaging.uiowa.edu/New_VolunteerRegistry/STAR_investigators.shtml
Author Biographies Jill Robertson, PharmD, is a PGY2 oncology pharmacy resident at The Nebraska Medical Center in Omaha, Nebraska. Karen B. Farris, PhD, is Charles R. Walgreen III professor in pharmacy administration, University of Michigan College of Pharmacy. Her research examines how older adults manage their medications and the roles of community and ambulatory pharmacists in influencing medication use, including public health issues. Susan K. Schultz, MD, is professor in the Department of Psychiatry at The University of Iowa Carver College of Medicine. Her research interests include the care and treatment of patients in late life who suffer from dementia such as Alzheimer’s disease. Ryan M. Carnahan, PharmD, MS, is clinical assistant professor in the Department of Epidemiology at The University of Iowa College of Public Health. His research interests include the pharmacoepidemiology of psychiatric medications and medication side effects, particularly among older adults.
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Brian Gryzlak, MA, MSW, is research specialist in the Department of Epidemiology at The University of Iowa College of Public Health. He coordinates several studies on emergent strategies to optimize appropriate medication use, primarily among older adults. Elizabeth A. Chrischilles, PhD, is professor and Marvin A. and Rose Lee Pomerantz chair in public health in the Department of Epidemiology at The University of Iowa College of Public Health. Her research uses health services epidemiology and health care effectiveness strategies to examine cancer outcomes in practice and medication use and effects among older adults.
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