International Journal of Clinical Pharmacy

, Volume 36, Issue 5, pp 904–913 | Cite as

Modified labels for long-term medications: influences on adherence, comprehension and preferences in Malaysia

  • Huan-Keat ChanEmail author
  • Mohamed Azmi Hassali
Research Article


Background Inability to read instructions on drug labels has been identified among the Malaysian population since 1990′s. Objective To assess the impact of font-enlarged and pictogram-incorporated labels used for long-term medications on patients’ adherence, comprehension and preferences. Setting Outpatient pharmacy in one of the major general hospitals across Northern Malaysia. Method This was a three-arm, randomized controlled trial. Outpatients with refill prescriptions of selected oral antihypertensive or antidiabetic medications were screened for eligibility. They were randomly allocated with standard (n = 35), font-enlarged (n = 40) or pictogram-incorporated (n = 35) labels. Assessment of baseline adherence scores using the 8-item Morisky Medication Adherence Scale, comprehension scores using a structured questionnaire and preferences was conducted upon recruitment. Follow-up telephone interviews were conducted after 4 weeks. Main outcome measure The changes of patients’ adherence and comprehension scores and their preferences. Results Within-group comparisons demonstrated an increase of total adherence scores after 4 weeks in all three groups (mean changes 0.35, 0.58 and 0.67; p = 0.029, 0.013 and 0.011, respectively). The repeatedly measured total comprehension score of pictogram-incorporated label group was significantly higher than baseline (mean change 0.37, p = 0.010). Two intervention groups obtained significantly higher scores for few items in both adherence and comprehension measurements after 4 weeks as compared with baselines. As indicated by F tests, three groups did not significantly differ in the changes of both total adherence and comprehension scores (p = 0.573 and 0.069, respectively) with the subjects’ age adjusted. Elderlies and those with a higher number of morbidity preferred pictogram-incorporated label over font-enlarged label. Conclusion We did not find a significant change of both adherence and comprehension levels after the introduction of modified medication labels. However, on the basis of within-group comparisons, they may have positive influences on certain aspects of patients’ adherence and comprehension. Variations in preferences may reflect the unique need of different subgroups in receiving written medication instructions.


Adherence Enlarged-font Malaysia Medication labels Pictogram 



We wish to thank the Director General of Health, Malaysia for his permission to publish this study. Assistance of the Kedah Clinical Research Centre and pharmacy staffs in data acquisition is also acknowledged.


This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflicts of interest

We have no conflicts of interest to disclose.


  1. 1.
    World Health Organization. Adherence to long-term therapies: Evidence for action. 2003. Accessed Jan 2014.
  2. 2.
    Axelsson M, Brink E, Lundgren J, Lotvall J. The influence of personality traits on reported adherence to medication in individuals with chronic disease: an epidemiological study in West Sweden. PLoS One. 2011;6:e18241.PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    Brown MT, Bussell JK. Medication adherence: WHO cares? Mayo Clin Proc. 2011;86:304–14.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Dowse R, Ehlers M. Medicine labels incorporating pictograms: do they influence understanding and adherence? Patient Educ Couns. 2005;58:63–70.PubMedCrossRefGoogle Scholar
  5. 5.
    Ramli A, Ahmad NS, Paraidathathu T. Medication adherence among hypertensive patients of primary health clinics in Malaysia. Patient Prefer Adherence. 2012;6:613–22.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Aziz AM, Ibrahim MI. Medication noncompliance: a thriving problem. Med J Malaysia. 1999;54:192–9.PubMedGoogle Scholar
  7. 7.
    Hassan NB, Hasanah CI, Foong K, Naing L, Awang R, Ismail SB, et al. Identification of psychosocial factors of noncompliance in hypertensive patients. J Hum Hypertens. 2006;20:23–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Turki AK, Sulaiman SAS. Elevated blood pressure among patients with hypertension in general hospital of Penang, Malaysia: does adherence matter? Int J Pharm Pharm Sci. 2010;2:24–32.Google Scholar
  9. 9.
    Ahmad NS, Ramli A, Islahudin F, Paraidathathu T. Medication adherence in patients with type 2 diabetes mellitus treated at primary health clinics in Malaysia. Patient Prefer Adherence. 2013;7:525–30.PubMedPubMedCentralGoogle Scholar
  10. 10.
    Katz MG, Kripalani S, Weiss BD. Use of pictorial aids in medication instructions: a review of the literature. Am J Health Syst Pharm. 2006;63:2391–7.PubMedCrossRefGoogle Scholar
  11. 11.
    Kripalani S, Yao X, Haynes RB. Interventions to enhance medication adherence in chronic medical conditions: a systematic review. Arch Intern Med. 2007;167:540–50.PubMedCrossRefGoogle Scholar
  12. 12.
    Conn VS, Hafdahl AR, Cooper PS, Ruppar TM, Mehr DR, Russell CL. Interventions to improve medication adherence among older adults: meta-analysis of adherence outcomes among randomized controlled trials. The Gerontologist. 2009;49:447–62.PubMedCrossRefGoogle Scholar
  13. 13.
    Viswanathan M, Golin CE, Jones CD, Ashok M, Blalock SJ, Wines RC, et al. Interventions to improve adherence to self-administered medications for chronic diseases in the United States: a systematic review. Ann Intern Med. 2012;157:785–95.PubMedCrossRefGoogle Scholar
  14. 14.
    Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353:487–97.PubMedCrossRefGoogle Scholar
  15. 15.
    Hassali MA, Thambyappa J, Nambiar S, Shafie AA. TRIPS, Free trade agreements and the pharmaceutical industry in Malaysia. In: Lofgren H, Williams OD, editors. The new political economy of pharmaceuticals: production, innovation and TRIPS in the Global South. Palgrave Macmillan: Basingstoke, 2013: 152-66. ISBN: 9780230284630.Google Scholar
  16. 16.
    Institute of Health Economics. Determinants and health related outcomes associated with nonadherence to prescribed drug regimens: a comparison of rural and urban home care clients. 2003.// 2003-02paper.pdf. Accessed Jan 2014.
  17. 17.
    Davis TC, Wolf MS, Bass PF 3rd, Thompson JA, Tilson HH, Neuberger M, et al. Literacy and misunderstanding prescription drug labels. Ann Intern Med. 2006;145:887–94.PubMedCrossRefGoogle Scholar
  18. 18.
    Canto De Cetina TE, Canto P, Ordonez Luna M. Effect of counseling to improve compliance in Mexican women receiving depot-medroxyprogesterone acetate. Contraception. 2001;63:143–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Vrijens B, Belmans A, Matthys K, de Klerk E, Lesaffre E. Effect of intervention through a pharmaceutical care program on patient adherence with prescribed once-daily atorvastatin. Pharmacoepidemiol Drug Saf. 2006;15:115–21.PubMedCrossRefGoogle Scholar
  20. 20.
    Schaffer SD, Tian L. Promoting adherence: effects of theory-based asthma education. Clin Nurs Res. 2004;13:69–89.PubMedCrossRefGoogle Scholar
  21. 21.
    Shrank W, Avorn J, Rolon C, Shekelle P. Effect of content and format of prescription drug labels on readability, understanding, and medication use: a systematic review. Ann Pharmacother. 2007;41:783–801.PubMedCrossRefGoogle Scholar
  22. 22.
    Central Intelligence Agency. The World Factbook. 2013. Accessed Jan 2014.
  23. 23.
    Sahril N, Mahmud SZ, Saari R, Naidu BM, Hamid HAA, Mutalip MHA. Medication labeling literacy among Malaysian with diabetes: a cross-sectional study. J Diabetes Res Clin Metab. 2012;1:23.CrossRefGoogle Scholar
  24. 24.
    Morisky DE, Ang A, Krousel-Wood M, Ward HJ. Predictive validity of a medication adherence measure in an outpatient setting (Greenwich). J Clin Hypertens. 2008;10:348–54.CrossRefGoogle Scholar
  25. 25.
    Al-Qazaz HKh, Hassali MA, Shafie AA, Sulaiman SA, Sundram S, Morisky DE. The eight-item Morisky Medication Adherence Scale MMAS: translation and validation of the Malaysian version. Diabetes Res Clin Pract. 2010;90:216–21.PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    Korb-Savoldelli V, Gillaizeau F, Pouchot J, Lenain E, Postel-Vinay N, Plouin PF, et al. Validation of a French version of the 8-item Morisky medication adherence scale in hypertensive adults (Greenwich). J Clin Hypertens. 2012;14:429–34.CrossRefGoogle Scholar
  27. 27.
    Taitel M, Jiang J, Rudkin K, Ewing S, Duncan I. The impact of pharmacist face-to-face counseling to improve medication adherence among patients initiating statin therapy. Patient Prefer Adherence. 2012;6:323–9.PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    Shrank WH, Gleason PP, Canning C, Walters C, Heaton AH, Jan S, et al. Can improved prescription labeling influence adherence to chronic medications? An evaluation of the target pharmacy label. J Gen Intern Med. 2009;24:570–8.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Mansoor LE, Dowse R. Effect of pictograms on readability of patient information materials. Ann Pharmacother. 2003;37:1003–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Houts PS, Doak CC, Doak LG, Loscalzo MJ. The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence. Patient Educ Couns. 2006;61:173–90.PubMedCrossRefGoogle Scholar
  31. 31.
    Mansoor LE, Dowse R. Medicines information and adherence in HIV/AIDS patients. J Clin Pharm Ther. 2006;31:7–15.PubMedCrossRefGoogle Scholar
  32. 32.
    Wogalter MS, Vigilante WJ Jr. Effects of label format on knowledge acquisition and perceived readability by younger and older patients. Ergonomics. 2003;46:327–44.PubMedCrossRefGoogle Scholar
  33. 33.
    Whatley S, Mamdani M, Upshur EG. A randomised comparison of the effect of three patient information leaflet models on older patients’ treatment intentions. Br J Gen Pract. 2002;52:483–4.PubMedPubMedCentralGoogle Scholar
  34. 34.
    Zargarzadeh AH, Law AV. Design and test of preference for a new prescription medication label. Int J Clin Pharm. 2011;33:252–9.PubMedCrossRefGoogle Scholar
  35. 35.
    MacLaughlin EJ, Raehl CL, Treadway AK, Sterling TL, Zoller DP, Bond CA. Assessing medication adherence: which in the elderly tools to use in clinical practice? Drugs Aging. 2005;22:231–55.PubMedCrossRefGoogle Scholar

Copyright information

© Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2014

Authors and Affiliations

  1. 1.Department of PharmacySultanah Bahiyah HospitalAlor SetarMalaysia
  2. 2.Discipline of Social and Administrative Pharamcy, School of Pharmaceutical SciencesUniversiti SainspenangMalaysia

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