Evid Based Nurs 9:22 doi:10.1136/ebn.9.1.22
  • Treatment

An educational booklet did not improve adherence or symptoms in patients prescribed thyroxine for primary hypothyroidism

 Q Does an educational booklet addressing lay health beliefs about medicine-taking improve adherence in patients prescribed thyroxine for primary hypothyroidism?



randomised controlled trial.


{not concealed}.*


blinded (laboratory staff assessing thyroid stimulating hormone [TSH] assays).

GraphicFollow up period:

median 96 days.


3 suburban general practices (18 physicians) in northwest England, UK.


332 patients ⩾18 years of age (mean age 62 y, 92% women) who were taking a stable dose of thyroxine (ie, dose unchanged over the previous 8 wks) for primary hypothyroidism caused by thyroidectomy, radio-iodine treatment, or autoimmune thyroiditis. Patients with serious illness were excluded.


166 patients were allocated to receive an educational booklet by post a few days after the initial assessment; the 7 page booklet, based on the health action model, addressed lay health beliefs about taking medication and included a medication reminder sticker and calendar. 166 patients were allocated to usual medical care.


change in individual patient TSH concentrations from baseline, scores on the Short Form 36 (SF-36) domains of vitality and general health, and a hypothyroid symptom index (modified Billewicz Hypothyroid Index).

GraphicPatient follow up:

99% (intention to treat analysis).


Patients who received the educational booklet did not differ from those who received usual care for mean within-patient change in TSH concentrations, vitality and general health on the SF-36, or symptoms on the hypothyroid index (table). Results for TSH concentrations were similar when analysis was adjusted for differences in baseline TSH concentrations.

An educational booklet v usual care for patients prescribed thyroxine for primary hypothyroidism


An educational booklet addressing lay health beliefs about medicine-taking did not improve adherence or symptoms in patients prescribed thyroxine for primary hypothyroidism.


  1. Barbara A Given, RN, PhD, FAAN
  1. Michigan State University
 East Lansing, Michigan, USA

      The study by Crilly and Esmail examined a low intensity educational intervention designed to enhance patient compliance with a medication important to the control of thyroid disease. The authors used a single approach intervention (an educational booklet), although several studies have shown that education alone does not bring about behaviour change.1

      Participants included 332 general practice patients who had thyroid disease and were taking thyroxine. The intervention was a simple one-time mailing of an educational booklet to patients. {No additional efforts were made to get patients involved in reading the booklet, and the involvement of the investigator was passive (merely mailing out materials)}.*

      Strengths of the booklet were its reading level, brevity (7 pages), and coverage of patients concerns. The authors indicated that the booklet was based on the health action model, but details about how the model related to the booklet were not provided. The materials did include a reminder calendar and sticker, but information about participants’ use of the calendar was not reported.

      The authors found that the groups did not differ for changes in TSH concentrations (measure of adherence), vitality and general health, or thyroid symptoms. Similar to other studies, these findings point out that simply providing informational material without additional support does not necessarily result in learning or behaviour change. However, despite not finding any differences between groups, the evaluation is an exemplar of how a well designed trial can challenge routine clinical practice (such as passively providing information and expecting change) and reveals that what makes us feel better may not benefit patients.


      • * Information provided by author.



      • * Information provided by author.

      • For correspondence: Dr M Crilly, Department of Public Health, University of Aberdeen Medical School, Aberdeen, UK. mike.crilly{at}

      • Source of funding: British Medical Association.

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