Improving health literacy of antifungal use-Comparison of the readability of antifungal medicines information from Australia, EU, UK, and US of 16 antifungal agents across 5 classes (allylamines, azoles, echinocandins, polyenes, and others)

Abstract

Adherence to antifungals is poor in high endemic regions where antifungal resistance is high. Poor readability of prescription/over-the-counter (OTC) antifungals may contribute to poor adherence, due to the patient not fully understanding the purpose, importance, and dosage of their antifungal medicine. As there are no reports on the readability of antifungals, this study examined the readability of patient-facing antifungal information. Antifungals (n = 16; five classes [allylamines, azoles, echinocandins, polyenes, and others-flucytosine and griseofulvin]) were selected. Readability of four sources of information, (i) summary of product characteristics, (ii) patient information leaflets (PILs), (iii) OTC patient information, and (iv) patient web-based information, was calculated using Readable software, to obtain readability scores [(i) Flesch Reading Ease [FRE], (ii) Flesch-Kinkaid Grade Level [FKGL], (iii) Gunning Fog Index, and (iv) Simple Measure of Gobbledygook (SMOG) Index) and text metrics [word count, sentence count, words/sentence, and syllables/word]. PILs, web-based resources, and OTC patient information had good readability (FRE mean ± sd = 52.8 ± 6.7, 58.6 ± 6.9, and 57.3 ± 7.4, respectively), just falling short of the ≥ 60 target. For FKGL (target ≤ 8.0), PILs, web-based resources, and OTC patient information also had good readability (mean ± sd = 8.5 ± 1.0, 7.2 ± 0.86, and 7.8 ± 0.1, respectively). Improved readability scores observed correlate with reduced words, words/sentence and syllables/word. Improving readability may lead to improved patient health literacy. Healthcare professionals, academics, and publishers preparing written materials regarding antifungals for the lay/patient community are encouraged to employ readability calculators to check the readability of their work, so that the final material is within recommended readability reference parameters, to support the health literacy of their patients/readers.

Keywords: antifungal; dermatophyte; fungal resistance; health literacy; readability.

Figure 1.

Box and whisker plot comparing readability scores for (A) Flesch Reading Ease (FRE); (B) Flesch–Kincaid Grade Level (FKGL); and text metric scores, (C) words per sentence and (D) syllables per word. These were calculated from (i) Summary of Product Characteristics (SPC), Source: Australian Register of Therapeutic Goods (ARTG) (n = 30); (ii) US Medication Guidance, Source: www.drugs.com (n = 30); (iii) Over-The-Counter (OTC) antifungals, Source: Patient information from UK High Street and online pharmacies (n = 30), and (iv) EU Patient Information Leaflets (PILs), Source :European Medicines Agency (n = 31). The box represents 25^th and 75^th percentile and the bar represents the median. Whiskers represent the 10^th and 90^th percentile and ● represent outliers outside these percentile ranges. For (A) FRE and (B) FKGL, statistical significance is shown, calculated using Anova with a posthoc Tukey's multiple comparisons test (parametric). For (C) Words per sentence and (D) Syllables per word, statistical significance is shown, calculated using the Kruskal–Wallis (non-parametric) test with Dunn's Adjusted p values. A P value of < .05 (5%) was considered as statistically significant. The dashed red line represents the target readability score. For the FRE, this is 60. For the FKGL score, this is ≤ 8.

Figure 2.

Box and whisker plot comparing (A) the Flesch Reading Ease (FRE) score and (B) the Flesch–Kincaid Grade Level (FKGL) for five classes of antifungal medicines (allylamines [terbinafine]; azoles [clotrimazole, econazole, fluconazole, itraconazole, ketoconazole, miconazole, posaconazole, and voriconazole]; echinocandins [anidulafungin, caspofungin, and micafungin]; polyenes [amphotericin B and nystatin]; and others [flucytosine and griseofulvin]). Antifungal information was obtained from patient-facing sources i.e., the US Medication Guidance, Source: www.drugs.com (n = 30) and (ii) EU Patient Information Leaflets (PILs), Source :European Medicines Agency (n = 31). The box represents 25^th and 75^th percentile and the bar represents the median. The dashed red line represents the target readability score (FRE 60; FKGR ≤ 8). Whiskers represent the 10^th and 90^th percentile and ● represent outliers outside these percentile ranges. Statistical significance is shown, calculated using Anova with a posthoc Tukey's multiple comparisons test (parametric). A P value of < .05 (5%) was considered as statistically significant. The box and whiskers plot comparing (C) the FRE score and (D) the FKGL for three formulations/routes of medicine administration (n = 58) comprising of orals (n = 29), iv (n = 17), and topical creams (n = 12). Antifungal information was obtained from patient-facing sources i.e., the US Medication Guidance, Source: www.drugs.com (n = 27) and (ii) EU PILs, Source :European Medicines Agency (n = 31). The box represents 25^th and 75^th percentile and the bar represents the median. The dashed red line represents the target readability score (FRE 60; FKGR ≤ 8). Whiskers represent the 10^th and 90^th percentile and ● represent outliers outside these percentile ranges. Statistical significance is shown, calculated using Anova with a posthoc Tukey's multiple comparisons test (parametric). A P value of < .05 (5%) was considered as statistically significant.