Council of Citizens with Low Vision, International

U.S. Access Board
1331 F Street, NW
Suite 1000
Washington, DC 20004-1111

Council of Citizens with Low Vision, International
Recommendations for Producing Large Print on Prescription Drug Container Labels and Accompanying Medication Usage Guides

Introduction

People with low vision are unique, being neither fully sighted nor totally blind. Visual acuity varies greatly; as does individual need. This is especially true regarding the wide range of criteria and guidelines that are used by printing houses and publishers to produce "large print" documents for people with low vision.
The order in which these recommendations appear below does not denote any ranking or relative importance.

Challenges

Some challenges that currently exist with large print on prescription drug container labels and accompanying medication usage guides:

• On large print versions of the Warning Labels, the symbols that correspond to the warnings often do not get enlarged to the same degree as the font.
  
• Many people who request large print materials need to use magnification devices to magnify to a greater degree, or to bring the paper to a good light source, in order to read them. It becomes easy to separate the paper from the medication.
• At the pharmacy point of sale the large print materials are often not given to the customer with the medication, but thrown away by personnel;
  • sometimes not realizing the importance to the customer;
    
  • sometimes thinking it is "junk" paper, or insignificant information that is not necessary for the customer to read;
    
  • sometimes completely missed in the packaging. Example: The medication may come in a large pouch and the personnel opens that up when the customer arrives to pick up the medication. The personnel gives the medication container to the customer, not realizing the large print material is in the pouch.
    
• Some materials are produced in a larger print, however, the font used is not clear enough to read. Some people may give up trying to read what is painful or difficult to read, therefore not gaining the important information.
  
• Some materials are enlarged via a photocopy machine, producing unclear print.
  
• Some materials are photocopied onto larger paper to accommodate the enlargement making the document difficult to work with.
  
• Some people are not aware that large print format is available, while that may be the very format needed in order to access the critical dosing and warning information required to prevent a grave mistake in taking improper dosing.

Recommendations:

Font size and style

• In general, at least an 18 point, and preferably a 20 point, bold, sans serif, mono or fixed space font is desirable. Adobe’s Verdana, Helvetica, Tahoma, Arial; Linotype’s Futura Light Bolded; and Typography’s Gotham Rounded fonts currently offer optimal readability for large print documents when the aforementioned parameters are applied.

Spacing

• Line spacing (leading) of at least 1.5, provide good readability and help reduce eye strain.
  
• Avoid "condensing" text to try to save space. The space between letters and words is important to a person with low vision.

Titles and Headings

• Titles and headings should be larger than the text of the document and contain both upper and lower case letters. Titles and headings should be aligned left where possible.
  
• All upper case should only be used in acronyms or limited to use as emphasis as in a warning: "Do NOT take this medication while operating machinery."

Layout

• Large print documents that display the text in blocked paragraphs which are aligned left are recommended. Double spacing between paragraphs is necessary for readability.

Bulleted text

• Bulleted text should be identified by large solid dark bullets, with double spacing between items.

"Widows" and "Orphans"

• Eliminate "widows" and "orphans" when continuing text from one page to the next.

Page numbers

• Page numbers should be the same font style and of at least the same font size as the document text.
  
• In single-sided, unbound documents, the page number should be positioned in the top right corner. Additionally, it is helpful to have the page number appear at the bottom center. In book formatted documents, the page number should be located in either the upper or lower outer corner of each page.
  In either case, a margin of at least 0.75 inches is needed to accommodate the page number.

Emphasis

• Emphasis is best achieved by the use of asterisks, dashes, double bolding, or by simply underlining an individual word. The use of color or italics is not acceptable for customers with low vision.

Columns and tables

• Horizontally connect two columns of information with leader dots, as in a table of contents. When a table appears in a large print document, it should be kept on one page. Horizontal and vertical lines between rows and columns will facilitate tracking in tables with multiple columns.

Binding

• If the information is on more than one sheet of paper they shall be stapled in upper left corner. Binding large print documents that are up to approximately 20 sheets of paper can be saddle stapled. Thicker documents must be bound with an appropriate spiral or wiro binding to facilitate flattening for ease of reading. An ample margin is needed to accommodate the binding.

Enlarging

• The enlargement feature on a copy machine does NOT produce large print documents. Copy machines create fuzzy text, which is often on oversized pages, making the document cumbersome. Using electronic editing and formatting on standard size paper will afford clear and usable large print documents, which is critical to the reader.

Formatting

• Properly format any bullets and numbered lists in the original document BEFORE converting to larger and clearer font so as to keep the formatting features and prevent skewing. i.e. If you create a numbered list and type the number, then space to type the text and then use spaces and tabs to align the text neatly underneath, that will become skewed when converted to large print and there will be extra lines and space and be impossible to track. It will also require extra paper.
  
• Depending on eye condition, some customers with low vision can read text that is presented in two columns, while others can read text in full width format. If your document has columns, it is recommended that the columned material is presented in the two formats; the first directing you to where the other option is located.
  Graphs, charts, and pictures
  
• Customers with low vision may have trouble with graphs, charts, and pictures in documents. An effort shall be made to isolate them on individual pages accompanied by explanatory captions.

High Visual Color Contrast

• Color and hue are not as important to those with low vision as high visual color contrast between a background and a text. The greater the difference between the "light reflectance values" (LRV) of two adjacent surfaces, the greater the contrast. Large print documents produced with a high degree of contrast results in maximum readability.

Paper used

• The paper used in large print documents shall have a matte or dull finish to reduce glare. An eggshell color minimizes eye strain.
  
• Paper used in large print documents shall be no less than twenty pound bond to avoid "bleed thru."
  
• Paper size shall NOT be larger than 8 ½" by 11". Larger paper is cumbersome and can be difficult to locate information, track text, and use with magnification devices whether large or portable.

Prescription Drug Container Labels

• Since standard prescription drug container labels are affixed to the prescription drug container, and because that is preferable so as to minimize the chance of losing the information, the large print labels are to be affixed to the prescription drug container. They should be attached in a way so as not to be separated from the container. A portion of the paper may be affixed to the container as with standard labels; folding the paper down to a manageable size.
  
• Also provide the 8 ½" by 11" format of the affixed label information. In this way the customer has an option of filing with other important papers, or viewing it with a magnifier or in a better light source.

Electronic format

• If electronic prescription drug container labels and accompanying medication usage guides are offered, provide in Rich Text Format (RTF) and follow the same recommendations of format for large print.

Warning labels and other information with symbols

• Since symbols that accompany warning labels are a very important visual cue to alert a customer to read about, for example, warnings regarding medication with alcohol, taking while pregnant, or sun exposure, these symbols must be comparably enlarged so as to be recognizable to the same degree as the text.

Self identification

• Often persons with low vision do not appear to have a visual impairment or have the need for large print. The range, degree and type of vision impairment varies greatly, and it is underestimated the number of customers who need large print.
  
• Self identification as a person requiring large print due to a visual impairment shall not be required. There are customers who do not consider themselves as having a visual impairment, although the standard labels and packaging materials are not usable to them.

Proactively marketing the availability

• It is critical that at the pharmacy point of sale, on websites, and on telephone order lines, the availability of large print must be widely communicated to ALL customers. This is because it may not only be the low vision customer picking up the prescription, or ordering it, but sometimes someone who is fully sighted (possibly a caregiver, or family member).

Training of pharmacy personnel

• To ensure effective delivery of prescription information in large print, pharmacy personnel must be trained regarding:
  
  • the availability of large print format for prescription labels, information sheets and product inserts to customers with visual impairments;
    
  • the procedures for receiving and processing requests for prescription information in large print;
    
  • informing customers about the availability of large print for prescription information;
    
  • inventory procedures for ensuring adequate availability of large print;
    
  • appropriate communications with customers with visual impairments.

Production of large print format

• Medication usage guides that accompany each container shall be produced in large print format by the manufacturer/distributor.
  
• Due to the critical nature of the individualized information contained on the prescription drug container labels, the large print format shall be produced at the pharmacy point of sale level.
  

Conclusion

• The implementation of the recommendations in this document will afford greater privacy, safety, and independence in taking medications while keeping the customer informed of critical information found in standard currently-used print.
  
• All pharmacy customers, whether fully sighted or visually impaired, have an expectation and a right to manage their medications independently and privately and to have the confidence that they are taking their medications safely, securely, and as prescribed. For pharmacy customers with visual impairments, the inability to read Prescription Drug Container Labels and Accompanying Medication Usage Guides puts them at serious risk of taking the wrong medication at the incorrect time and in the improper dosage, to the jeopardy of their health and safety. Without having ready access to their prescription information, customers with visual impairments are also at risk of taking expired medications, of not being able to timely obtain refills, and of being unable to detect pharmacy errors.

Questions and/or comments regarding this document may be directed to:

Annette Carter,
Council of Citizens with Low Vision, International
559-355-4095
annette.carter@pacbell.net
www.cclvi.org