SSM Patient Information Leaflet: The production of a patient information leaflet
The case for a new leaflet
The characteristics and needs of the patient group
Women in the UK have a wide range of contraception available to them but many are not aware of, or do not fully understand, the choices available. Methods to prevent pregnancy range from well-known methods such as the Oral Contraceptive Pill (OCP) or condoms, through to less familiar types such as Long Acting Reversible Contraceptives (LARC) and natural family planning. Patient information has long been available for the more well known contraceptive methods and exists in a variety of media. The same is not true however for LARC.
It is has been estimated that four in ten pregnancies in the UK are unplanned. In a survey of 3,000 mothers, almost half of these women with unplanned pregnancies were using contraception and of these 62% blamed problems with the OCP, 19% were associated with a split condom, and 3% were using contraception infrequently. This survey further showed that 70% of women on the OCP forget to take it at least once a month, 10% forgetting to take it four times or more. When asked about a new method of contraception only 15% were considering an alternative method listed as ‘contraceptive patch or injection', with no direct mention of LARC.
The Family Planning Association (FPA) estimates that 25% of British women aged between 16-49 use the OCP, whilst only 9% use one of the four LARC methods currently licensed. In a recent FPA telephone survey, 76% of current OCP users said they had never heard of the Intrauterine System (IUS), 34% were unaware of the Intrauterine Device (IUD), 24% did not know about the contraceptive implant and 12% had not heard of the injection. NICE has recommended the use of LARC since October 2005 to improve patient choice and cost effectiveness. It is estimated that if the use of implants and the IUS increased by just 9%, the NHS would save around £33 million a year in costs currently incurred by abortion and maternity services as a result of unplanned pregnancies.
Given that there is currently a strategy in place to reduce the under-18 conception rate by 50% by 2010, there is perhaps no better time to promote LARC usage, an established and reliable form of contraceptive. The department of health (DOH) further supports this view by including LARC into the Quality and Outcomes Framework (QOF) for 2009/10.
Existing patient information leaflets
At this time there is only one existing nationally recognised information source on LARC and this focuses on NICE guidance[i] rather than patient advice. This guide was produced and distributed five years ago by NICE to general practices and other healthcare centres. It is, however, no longer distributed but available to be downloaded from the NICE website.
Given that this guidance was produced by NICE it follows clinical governance, but it is however, not in itself a patient information leaflet. As an information leaflet it is sound in layout, however, it is out of date in content and not patient focused. The FPA has reviewed this fact and are considering producing an information leaflet. In all clinical settings I have not personally been able to access a patient information leaflet relevant to LARC.[ii]
The production process
The aim of this patient information leaflet is to provide females of reproductive age a greater choice of contraceptive methods inline with NICE guidance. The use of LARC also follows frameworks and policy strategies that are in place to reduce the number of unplanned pregnancies with particular emphasis in those under 18. It is in this younger patient group where I sought opinions on the current information that is available. In a recent audit of LARC consultations and usage amongst 12-21 year old female patients registered to a general practice, 82% were found to be sexually active, half of these had been consulted about the use of a LARC, but only 18% were currently using a LARC. [iii] When further broken down, it appeared that those who were on a LARC had received extra counselling and further information. The information in this instance was either from verbal explanation, reference to internet resources and in most cases no information leaflet or NICE guidance was given. Following the outcome of this audit I approached both the specialist nurses who provided the information and a select patient group who had been consulted on LARC usage. The overwhelming response was that the NICE guidance information was not accessible or patient friendly. A simpler and concise version to suit the needs of this patient group became the initial focus of the information leaflet production.
The first draft was reviewed by the above mentioned groups and can be summarised as follows:
· Too much text information
o The groups thought that the first draft was too wordy despite the fact it was considerably less compared to the alternative. All agreed that the text was readable and free from medical jargon but needed to be more concise.
· Not enough images
o The patient group said that they would be encouraged to read more if there were graphics to coincide with each of the different methods of LARC. It was felt that their level of understanding would improve if graphics were to be used.
· Confusing comparison table of each individual LARC
o In the initial draft a table to compare each LARC was included. Although simpler in content compared to the NICE guidance it was felt that is was too much information to read and to comprehend. It was felt that each individual LARC should be mentioned separately and preferably on an individual side of A5.
· Lack of a glossary
o Even though medical jargon had not been used both groups felt that a summary or glossary would be helpful to reinforce some of the key terms or concepts used.
· Contact groups
o The nurse specialists thought it was necessary to include the details of relevant allied healthcare services in the leaflet. This would give those who wanted further information the option and as an added benefit the ability to advertise other healthcare services and provisions.
Following this initial consultation and other communications the draft was modified to take into account the above mentioned suggestions. To accommodate these changes the entire layout of the leaflet needed to be redesigned. Following the second draft it became apparent that the body text was in fact more readable and comprehendible if supported by appropriate graphics. It was also apparent that having each individual method of LARC on a separate page added clarity and avoided confusion caused by the initial summary table on each method. Furthermore this table had to be orientated horizontally on the page rather than vertically due to its size which the group felt made it difficult to read. After removing this table, reducing the text volume and adding graphics I felt that perhaps the leaflet had become perhaps too focused towards this particular patient group, a younger female population. On further discussion with the nurse specialists it was agreed that this was in fact the target population and coincides nicely with national frameworks as previously discussed. It was felt that those who wanted more information would seek it i.e. the older, perhaps further educated patient group, rather than providing all the facts and limiting the interest in the younger population. The final draft was presented and approved by both groups and access to this leaflet was discussed with the possibility of it being uploaded to an internet site for added convenience.[iv]
The new leaflet
The final version
* Please see the final version of this patient information leaflet along with the original attached to this document.
* To ensure that this leaflet met the requirements
* Quote: 10,000 A5 with colour £1100
* Description of how your leaflet will be used
1. Carrigan, R. et al. 2009. An Audit of LARC consultations and usage in Rushall Medical Practice, Walsall, West Midlands. Unpublished.
7. The Teenage Pregnancy Strategy, 1999. Accessed: http:// direct.gov.uk/
9. Office for national statistics. 2009. Accessed: http://neighbourhood.statistics.gov.uk
 FPA 2009
 commissioned by evriwoman.co.uk
 commissioned by evriwoman.co.uk
 NICE XXX date
 The Teenage Pregnancy Strategy, 1999
 DOH QOF
 NICE, 2005
 FPA 2009
[i] Understanding NICE guidance -
this information source was issued to support the full NICE guidance on LARC in 2005 and to make patients aware of the services that should be available to them. However, it is not in fact a patient information leaflet as such but has been used as one for many years in general practices rather than for its intended purpose as a supplementary summary to the full guidance on LARC. In all clinical settings this is the only information leaflet that has been made available. I am however sure that information is likely to be widely available online but not in a leaflet form at this time and certainly not for all the LARC methods together.
[ii] Section 1 - total word count 519
[iii] This audit was carried out in Rushall, Walsall where the number of teenage pregnancies has reduced to 53.5 per 1,000 since 1998 but is still way above the national average of 40.6 per 1,000. The levels of poverty and educational outcomes are below the national average which is an associated causative factor for the high rate of teenage pregnancies.0 A great deal of government money has been spent to support The Teenage Pregnancy Strategy for this targeted region. Arguably the increased uptake of LARC will not only help to reduce the unplanned pregnancy rate but will also allow the recuperated funds to be diverted for other healthcare demands.