Use of a Pictographic Diagram to Decrease Parent Dosing Errors With Infant Acetaminophen: A Health Literacy Perspective

doi:10.1016/j.acap.2010.12.007

Academic Pediatrics

Volume 11, Issue 1, January–February 2011, Pages 50-57

Preliminary data from this study were presented at a stakeholder meeting of the US Centers for Disease Control and Prevention, Preventing Unsupervised Medication Ingestions and Overdoses in Children, November 13, 2008, and at the 2009 Pediatric Academic Societies meeting.

https://doi.org/10.1016/j.acap.2010.12.007 Get rights and content

Abstract

Objective

Medication dosing errors by parents are frequent. We sought to whether a pictographic dosing diagram could improve parent ability to dose infant acetaminophen, and to determine whether pictogram benefit varies by health literacy level.

Methods

We conducted an experimental study of parents presenting with their children to an urban public hospital pediatric clinic. Caregivers were randomized to dose infant acetaminophen with a standard dropper using text-only or text-plus-pictogram instructions (pictographic diagram of dose). The primary outcome variable was dosing accuracy (error defined as >20% deviation above/below dose; large overdosing error defined as >1.5 times recommended dose). Caregiver health literacy was assessed by means of the Newest Vital Sign measure.

Results

A total of 299 parents were assessed (144 text-only instructions; 155 text plus pictogram); 77.9% had limited health literacy (Newest Vital Sign score 0–3). Text-plus-pictogram recipients were less likely to make an error compared to text-only recipients (43.9% vs 59.0%, P = .01; absolute risk reduction, 15.2% [95% confidence interval, 3.8–26.0]; number needed to treat, 7 [4–26]). Of text-plus-pictogram recipients, 0.6% made a large overdosing error compared to 5.6% of text-only recipients (absolute risk reduction, 4.9% [0.9–10.0]; number needed to treat, 20 [10–108]). Pictogram benefit varied by health literacy, with a statistically significant difference in dosing error evident in the text-plus-pictogram group compared to the text-only group among parents with low health literacy (50.4% vs 66.4%; P = .02), but not for parents with adequate health literacy (P = .7).

Conclusions

Inclusion of pictographic dosing diagrams as part of written medication instructions for infant acetaminophen may help parents provide doses of medication more accurately, especially those with low health literacy. High error rates, even among parents with adequate health literacy, suggest that additional study of strategies to optimize dosing is needed.

Section snippets

Design

An experimental design was used to assess whether parents given a pictographic dosing diagram along with text instructions would make fewer dosing errors with infant acetaminophen compared to parents given text-only instructions. Institutional review board approval was obtained from the New York University School of Medicine and Bellevue Hospital Center.

Participants, Recruitment, and Randomization

A convenience sample was enrolled of parents presenting with their child to the pediatric outpatient clinic at Bellevue Hospital Center, an

Results

From October through December 2008, a sample of 302 caregivers were enrolled. Research assistants approached study subjects as they waited with their children to be seen for their appointment; approximately two-thirds agreed to participate. Of those who refused to participate, most refused as a result of concern about missing or being delayed for their appointment.

Of 302 parents, 3 caregivers did not complete the dosing assessment and were therefore excluded from analyses. A total of 299

Discussion

This study reveals that many parents, especially low SES parents, have difficulty dosing infant acetaminophen, with over half of parents in our sample making errors. Of particular concern, 5% of parents receiving standard instructions in our study made overdosing errors of 1.5 times above the recommended dose.

The high rate of dosing error we found is consistent with prior studies examining parent dosing accuracy with liquid medications.1, 2, 3, 18, 22 Although there has been limited study of

Acknowledgment

This research was supported in part by a grant under The Robert Wood Johnson Foundation Physician Faculty Scholars Program (Dr Yin). At the time the study was conducted, Dr Yin was supported by the Pfizer Fellowship in Health Literacy/Clear Health Communication. Funding for this project was also provided by KiDS of NYU and the NYU School of Medicine Department of Pediatrics Joseph Dancis Research Fund.

Additional contributions Nancy Linn, MFA, helped design the graphics used in the study.

References (46)

H.S. Yin et al.
Association of low caregiver health literacy with reported use of non-standardized dosing instruments and lack of knowledge of weight-based dosing
Ambul Pediatr
(2007)
P.S. Houts et al.
The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence
Patient Educ Couns
(2006)
R. Dowse et al.
Medicine labels incorporating pictograms: do they influence understanding and adherence?
Patient Educ Couns
(2005)
L.N. Ngoh et al.
Design, development, and evaluation of visual aids for communicating prescription drug instructions to nonliterate patients in rural Cameroon
Patient Educ Couns
(1997)
E.C. Hanson
Evaluating cognitive services for non-literate and visually impaired patients in community pharmacy rotation sites
Am J Pharmaceut Educ
(1995)
P.E. Austin et al.
Discharge instructions: do illustrations help our patients understand them?
Ann Emerg Med
(1995)
C.D. Bethell et al.
Comparison of the children with special health care needs screener to the questionnaire for identifying children with chronic conditions—revised
Ambul Pediatr
(2002)
C.D. Bethell et al.
Identifying children with special health care needs: development and evaluation of a short screening instrument
Ambul Pediatr
(2002)
P.C. van Dyck et al.
The national survey of children with special health care needs
Ambul Pediatr
(2002)
K.S. Frush et al.
Evaluation of a method to reduce over-the-counter medication dosing error
Arch Pediatr Adolesc Med
(2004)

B. Gribetz et al.

Underdosing of acetaminophen by parents

Pediatrics

(1987)

H.K. Simon et al.

Over-the-counter medications. Do parents give what they intend to give?

Arch Pediatr Adolesc Med

(1997)

A.C. Bronstein et al.

2008 Annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 26th annual report

Clin Toxicol

(2008)

US Food and Drug Administration. Briefing Information for the June 29–30, 2009, Joint Meeting of the Drug Safety and...

H.S. Yin et al.

Parents’ medication administration errors: role of dosing instruments and health literacy

Arch Pediatr Adolesc Med

(2010)

H.S. Yin et al.

The health literacy of parents in the United States: a nationally representative study

Pediatrics

(2009)

M.G. Katz et al.

Use of pictorial aids in medication instructions: a review of the literature

Am J Health System Pharm

(2006)

D.G. Morrow et al.

Icons improve older and younger adults’ comprehension of medication information

J Gerontol B Psychol Sci Soc Sci

(1998)

C. Delp et al.

Communicating information to patients: the use of cartoon illustrations to improve comprehension of instructions

Acad Emerg Med

(1996)

R. Michielutte et al.

The use of illustrations and narrative text style to improve readability of a health education brochure

J Cancer Educ

(1992)

H.S. Yin et al.

Randomized controlled trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence among caregivers of young children

Arch Pediatr Adolesc Med

(2008)

E.J. Mayeaux et al.

Improving patient education for patients with low literacy skills

Am Fam Physician

(Jan 1996)

D. Schillinger et al.

Closing the loop: physician communication with diabetic patients who have low health literacy

Arch Intern Med

(Jan 13 2003)

Cited by (83)

Stepping into small shoes: Gaining user perspective on appropriate administration devices for paediatric medication in India
2023, European Journal of Pharmaceutics and Biopharmaceutics
A cross sectional pan-India study about use of administration devices for paediatric oral and inhalation medicines was conducted with a diverse pool of participants of various age groups. Via 634 respondents from more than 15 states in India, this study has identified the administration devices commonly used by parents/caregivers for children 0 to 18 years and by children over 10 years. It has provided insights on device ease of use, challenges faced and recommendations to facilitate the correct use of administration devices for paediatric oral and inhalation medicines. Ethics approval (DPSRU-BREC/2020/A/008)) was obtained from the Biomedical Research Ethics Committee of Delhi Pharmaceutical Sciences and Research University.
The survey was completed by parents only (n = 514) and jointly by both parents and children (n = 120). The mean age of the child was 7.2 ± 4.96 years. 72% of the respondents reported that an oral medicine had been taken recently, 6.3% reported that an inhaled medicine had been taken and the remaining 21.9% reported that both an oral and inhaled medicine had been taken. The use of measuring cup was most prevalent followed by household spoons. The mean of the score for ease of use was found to be highest 4.6 ± 0.50 for oral syringe and lowest (3.8 ± 0.76) for measuring cups. The majority of them found the oral device easy to use. Difficulties were reported mostly for measuring cups and household spoons and were related to a lack of user instructions and measuring difficulties. The respondents who found the device easy to use had mostly received clear instructions from healthcare professionals.
Compared to oral devices, there were very limited responses for inhalation devices (n = 175/634). Nebulisers with facemasks were most frequently used followed by manually actuated Metered dose inhalers with and without spacer. The mean of the ease-of-use score for dry powder inhalers was found to be highest (4.2 ± 0.37) followed by mist inhalers (4.0 ± 0) and manually actuated pressurised metered dose inhalers (4.0 ± 0.71). The nebulisers with facemask were reported to be difficult to use by most of the respondents despite receiving clear instructions from healthcare professionals.
The study findings add evidence to the understudied area of user experiences and perspectives on administration devices for oral and inhalation medicines in India. It highlights a need for initiatives to improve the usability, availability, and affordability of administration devices for children in India. Awareness on the importance of proper use of devices needs to be raised and sustained about the existence of affordable administration devices.
Association between YouTube® videos and health literacy with postoperative healthcare utilization following pediatric urologic surgery: A randomized trial
2023, Journal of Pediatric Urology
Limited caregiver health literacy has been associated with poorer health outcomes in pediatric patients and may limit caregiver understanding of printed education resources. Postoperative healthcare utilization may be related to confusion about instructions or complications.
To correlate caregiver health literacy and educational video intervention with postoperative healthcare utilization following ambulatory pediatric urologic surgery.
From July through December 2021, a randomized double-blinded trial assessed postoperative healthcare utilization following pediatric urologic surgery. Caregivers were randomized to receive standardized postoperative counseling and printed instructions (control) or access to English-language educational YouTube® videos with standardized postoperative counseling and printed instructions (intervention). Medical record abstraction was completed 30 days following surgery to identify postoperative healthcare utilization with calls, messages, add-on clinic visits, or presentation for urgent or emergent care, and postoperative complications.
Target enrollment was achieved with 400 caregivers with 204 in the intervention and 196 in the control groups. There was a 32.5 % overall rate of postoperative healthcare utilization. Health literacy was inversely associated with total postoperative healthcare utilization (p < 0.001). There was no difference in the incidence of postoperative healthcare utilization between the control and intervention groups (p = 0.623). However, on sub-analysis of caregivers with postoperative healthcare utilization (Summary Figure), there were fewer total occurrences in the intervention group (intervention median 1, IQR 1,2.3; control median 2, IQR 1,3; p < 0.001).
For caregivers with limited health literacy, there was a greater associated reduction in median calls from 2 (IQR 0,2) to 0 (IQR 0,0.5) with video intervention (p = 0.016). On multivariate analysis, total postoperative healthcare utilization was significantly associated with limited caregiver health literacy (OR 1.08; p = 0.004), English as preferred language (OR 0.68; p = 0.018), and older patient age (OR 0.95; p = 0.001).
Current resources for postoperative education are limited as resources can be written above recommended reading levels and families can have difficulty recalling information discussed during postoperative counseling. Video intervention is an underutilized resource that can provide an additional resource to families with visual and auditory aids and be accessed as needed.
Caregiver health literacy was inversely associated with postoperative healthcare utilization. There was no difference in the incidence of postoperative healthcare utilization with video intervention. However, on subgroup analysis, supplemental videos were associated with fewer occurrences of postoperative healthcare utilization, especially in caregivers with limited health literacy. On multivariate regression, health literacy, preferred language, and patient age were significantly associated with total postoperative healthcare utilization.
The promise of patient-directed decision support
2023, Clinical Decision Support and beyond: Progress and Opportunities in Knowledge-Enhanced Health and Healthcare
Clinical decision support, focused on providing timely information to clinicians to support evidence-based decision-making, has been a major theme of informatics research. By contrast, patient-directed decision support (support directed toward patients) has attracted less attention in the field. Patient-directed decision support involves supporting patients and their caregivers, with or without their care teams, in health-related decisions and actions. Information alone is not sufficient to support patient decisions: information about a decision must be accompanied by methods of eliciting patient values and preferences, guidance about how to apply values and preferences to decisions, and support for patient-provider shared decision making discussions. Technological solutions for patients include decision aids for one-time decisions and disease management systems for recurring disease-related decisions. All solutions for patients must consider technology access and literacy, self-efficacy for decision making, health literacy and numeracy, and implementation into workflow. Bringing informatics awareness to this important work could strengthen the field by ensuring that the tools patients need for decisions are grounded in the best evidence, developed with attention to patient needs and requirements, and (where appropriate) integrated into clinical systems, teams, and workflow.
Strategies to optimize comprehension of numerical medication instructions: A systematic review and concept map
2022, Patient Education and Counseling
Citation Excerpt :
Five studies evaluated liquid dosing visualizations, four with caregivers of pediatric patients, and one with adults [14,43,53–55]. Three of these used concrete icons of syringes to demonstrate the fill line for the correct dose [14,43,53]. The other two included abstract, direct icon images of droppers filled to the appropriate line [54,55].
To develop evidence-based recommendations for improving comprehension of quantitative medication instructions.
This review included a literature search from inception to November 2021. Studies were included for the following: 1) original research; 2) compared multiple formats for presenting quantitative medication information on dose, frequency, and/or time; 3) included patients/lay-people; 4) assessed comprehension-related outcomes quantitatively. To classify the studies, we developed a concept map. We weighed 3 factors (risk of bias in individual studies, consistency of findings among studies, and homogeneity of the interventions tested) to generate 3 levels of recommendations.
Twenty-one studies were included. Level 1 recommendations are: 1) use visualizations of medication doses for liquid medications, and 2) express instructions in time-periods rather than times per day. Level 2 recommendations include: validate icons, use panels or tables with explanatory text, use visualizations for non-English speaking populations and for those with low health literacy and limited English proficiency.
Visualized liquid medication doses and time period-based administration instructions improve comprehension of numerical medication instructions. Use of visualizations for those with limited health literacy and English proficiency could result in improved outcomes.
Practitioners should use visualizations for liquid medication instructions and time period-based instructions to improve outcomes.
Prescribing in a pediatric hospital setting – Lost in translation?
2022, Patient Education and Counseling
To determine parental understanding of directions on common pediatric prescription pharmacy labels and to identify enablers and barriers that affect interpretation of these labels.
Prospective qualitative descriptive study (July to August 2020) of 20 parents in post-surgical wards at a single Australian tertiary pediatric center.
Four key themes emerged through inductive analysis of the interview transcripts: 1) the addition of specific directions, such as administration with/without food and treatment course duration were perceived to be beneficial; 2) explicit phrasing of dosing intervals and times were more easily interpreted; 3) the use of simpler and common terminology enhanced understanding of the directions; and 4) presentation of multiple-step directions (e.g. tapering regimens) in a simplified and more organized manner was identified as an enabler and was thought to reduce confusion.
Differences in wording and presentation of pediatric prescription medication label directions led to variable interpretation by parents.
Therefore, there is a need for guidelines to standardize the wording of prescription medication advice labels. Findings from this study can be used to achieve this goal.
The impact of using pictorial aids in caregivers’ understanding of patient information leaflets of pediatric pain medications: A quasi-experimental study
2022, Saudi Pharmaceutical Journal
Patient information leaflets (PILs) are one of the main sources of information for over-the-counter medications (OTCs). This study aimed to assess caregivers' understanding of instructions in PILs provided with paracetamol medications and the impact of pictograms use.
A quasi-experimental study was conducted among caregivers of children aged < 13 years recruited in pediatric outpatient clinics at University Medical City in Riyadh. The calculated sample size was 128; at least 64 participants were needed in each group (the text-only group and the text-plus pictograms group). Caregivers' health literacy was assessed using a validated Arabic version of the Newest Vital Sign scale. Participants’ understanding of PILs instructions was assessed using eight questions on the route of administration, minimal hours between doses, max daily dose, shake medication before use, storage, and reporting adverse events; and was rated based on the number of questions correctly understood. Characteristics of participants were compared by Pearson X² and t-test was used to assess the significance of mean score differences between groups.
A total of 130 caregivers participated in the study; almost half of them were mothers (47%, [n = 61]) and 43% (n = 56) have “a possibility of limited health literacy”. The mean number of correct answers to questions assessing the understanding of PILs instructions was significantly higher among the text-plus pictograms group compared to the text-only group (5.25 ± 1.85 vs. 4.38 ± 1.27; p < 0.001). When results were controlled for age and gender, better health literacy was found to be associated with a better understanding of instructions (B = 0.39, 95 %CI 0.23–0.54).
Limited comprehension of medications instructions was observed; adding pictorial aids to PILs might enhance the comprehension. Differences in health literacy levels of caregivers should be considered when designing PILs.

View all citing articles on Scopus

: The authors have no conflicts of interest to disclose.

View full text

PreventionUse of a Pictographic Diagram to Decrease Parent Dosing Errors With Infant Acetaminophen: A Health Literacy Perspective

Abstract

Objective

Methods

Results

Conclusions

Section snippets

Design

Participants, Recruitment, and Randomization

Results

Discussion

Acknowledgment

Ambul Pediatr

Patient Educ Couns

Patient Educ Couns

Patient Educ Couns

Am J Pharmaceut Educ

Ann Emerg Med

Ambul Pediatr

Ambul Pediatr

Ambul Pediatr

Evaluation of a method to reduce over-the-counter medication dosing error

Arch Pediatr Adolesc Med

Underdosing of acetaminophen by parents

Pediatrics

Over-the-counter medications. Do parents give what they intend to give?

Arch Pediatr Adolesc Med

2008 Annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 26th annual report

Clin Toxicol

Parents’ medication administration errors: role of dosing instruments and health literacy

Arch Pediatr Adolesc Med

The health literacy of parents in the United States: a nationally representative study

Pediatrics

Use of pictorial aids in medication instructions: a review of the literature

Am J Health System Pharm

Icons improve older and younger adults’ comprehension of medication information

J Gerontol B Psychol Sci Soc Sci

Communicating information to patients: the use of cartoon illustrations to improve comprehension of instructions

Acad Emerg Med

The use of illustrations and narrative text style to improve readability of a health education brochure

J Cancer Educ

Randomized controlled trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence among caregivers of young children

Arch Pediatr Adolesc Med

Improving patient education for patients with low literacy skills

Am Fam Physician

Closing the loop: physician communication with diabetic patients who have low health literacy

Arch Intern Med

Prevention
Use of a Pictographic Diagram to Decrease Parent Dosing Errors With Infant Acetaminophen: A Health Literacy Perspective