Medication Safety: "Comprende" Not Necessarily

Dr. Gaunt is a medication safety analystand the editor of ISMP MedicationSafety Alert! Community/AmbulatoryCare Edition.

Many people have trouble adheringto a prescribed plan of care.Some limits occur as a resultof emotional distress, clinical condition,or socioeconomic factors. Pharmacists,however, also should consider the possibilitythat poor health literacy is a barrierto adherence for many patients. Olderpatients, people with chronic diseases,and patients who do not speak English astheir primary language, or at all, are especiallylikely to exhibit low health literacy.

ISMP received a report from a communitypharmacist who works in a settingwhere 90% of her patients are Spanish-speaking.An elderly man, who did notspeak or read English, returned to thepharmacy for more information afterhaving taken a portion of a methylprednisolonedose pack. He had not receivedappropriateinstructions about how toadminister this complicated dosing regimen,and he was not taking the medicationcorrectly. Fortunately, the gentleman wasnot harmed, but he did not receive the fullintended benefits of the drug either.

Studies have shown that 36% ofAmericans function at the basic healthliteracy level or lower.¹ It is even moresignificant (66%) for Americans ofHispanic race/ethnicity. Furthermore,a national managed care organizationstudy described the literacy of 54% ofSpanish-speaking Medicare enrolleesto be inadequate or marginal.²

Keep in mind, too, that not all patientswho speak Spanish can understand medicationinstructions written in Spanish.A 2004 study among Spanish-speakingLatino parents with limited Englishproficiency who were given prescriptionlabels in English and correspondingmedication information leaflets inSpanish exemplified this fact.³ The parentswere asked to read the medicationlabel and the information sheet andthen answer questions regarding themedication and proper dosing. Of the100 study participants, only 22% wouldhave given a correct dose of medicationto their child. In addition, only 29% wereable to answer questions regarding themedicine dosage and proper use as aresult of having access to written informationin Spanish. Also noteworthy inthe study was the fact that even amongindividuals who self-described themselvesas being comfortable speakingEnglish, only 50% were able to demonstrateknowledge that would allowthem to accurately prepare a dose oftheir child’s medication.

Safe Practice Recommendations

In order to help individuals of thispatient population use medicationssafely, a number of interventions mustbe employed. Here are some suggestionsthat can make patient educationsessions more successful.

• Assess a patient’s level of comprehension.The Short Assessmentof Health Literacy for Spanish-speakingAdults, a screening tool, identifiesSpanish-speaking adults with lowhealth literacy.⁴ Notations should bemade in these patients’ profiles andcharts to alert practitioners and fostersupplemental education for thesepatients at each follow-up visit.
• Supply language-appropriate patientinformation. Consider placingSpanish-speaking pharmacistsin areas with a high percentageof Spanish-speaking patients.In practices with fewer Spanish-speakingpatients, forge a workingrelationship with a pharmacistwho is fluent in Spanish to assistin patient counseling. Also, theNational Library of Medicine andthe National Institutes of Health(www.nlm.nih.gov) have easy-toreadmedication information leafletsin both English and Spanish.
• Provide small amounts of verbalinformation at a time. First,in simple everyday language, tellpatients what they truly need toknow to take their medicationssafely and to identify important sideeffects. Emphasize desired behavior,not the medical facts. Leaveextensive overviews of interactionsand side effects for later encounters.Avoid using medical terminologyand jargon.
• Use multimedia visuals. Anotherstrategy to consider for patients withlow health literacy is the use of multimediavisuals aids, such as video,audiotapes, and CDs, preferably inthe patient’s primary language.
• Verify patients' understanding.Use the Teach-Back Methodto counsel patients. Avoid asking“yes” or “no” questions. Instead, askpatients to show and tell you, intheir own words, how they wouldtake their medicine.

References

• Kutner M, Greenberg E, Jin Y, Paulsen, C. The Health Literacy of America's Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006-483). US Department of Education. Washington, DC: National Center for Education Statistics. 2006.
• Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA. 1999;281(6):545-551.
• Leyva M, Sharif I, Ozuah PO. Health literacy among Spanish-speaking Latino parents with limited English proficiency. Ambul Pediatr. 2005;5(1):56-59.
• Lee SY, Bender DE, Ruiz RE, Cho YI. Development of an easy-to-use Spanish Health Literacy test. Health Serv Res. 2006;41(4 Pt 1):1392-1412.