Patient Understanding: The Cornerstone of Medication Adherence

Low health literacy can be a major obstacle to the proper use of medications.

What percentage of patients walk out of your pharmacy not knowing how to use their medicine correctly? According to the Institute of Medicine, nearly half of US adults will have some difficulty understanding their medication instructions.¹ These patients have low health literacy. With 4.3 billion prescriptions dispensed in the United States last year, this challenge has the potential to affect a substantial number of patients.

What Is Health Literacy?

Health literacy is a personal skill that includes the ability to gather, understand, and act on appropriate health information. Patients with low health literacy have difficulty with one or more of these steps. Each step is important because an inability at any stage detrimentally affects subsequent steps. Health literacy is such an important skill that it is a stronger predictor of health than age, income, employment status, and race.²

Why Is Health Literacy Important for Pharmacists to Consider?

Addressing health literacy is important because it offers a practical approach to improving patient adherence by directly impacting the patient’s ability to selfmanage their medications. Let us take a look at each of the 3 health literacy skills to see what we can do to overcome low health literacy:

Gathering—Many patients do not know where to go to find information about their medicines. The Internet has so much information—from both reputable and nonreputable sources—that many people quickly become overwhelmed. Therefore, once information is collected, patients often have a tough time sifting through credible information to find actionable content.

Pharmacists can make this process easier for patients by guiding them to reputable resources. One such resource is MedLine Plus from the National Library of Medicine. If a patient does not have Internet access, consider giving him or her a printout of pertinent information. A good rule of thumb is that half of all people forget what you tell them once they walk out the door, so giving them printed information is always a good decision.

Understanding—Approximately 1 in 8 patients has some vision loss.³ If patients have difficulty reading, it is hard for them to understand instructions. As our population becomes older, vision loss is becoming increasingly prevalent. Ask if your patients wish to receive information in larger font sizes or if they need help reading the material. Check to see if you can print larger font sizes on bottles and in handouts.

Another 30 million Americans have limited English proficiency. If patients cannot read the English instructions, this is an obvious barrier to understanding them and a safety concern. There are a few vendors who now offer multilanguage medication instructions for patients. Avoid giving just the dense, English-only medication instruction sheets that have been dispensed with medicines in the past, hoping that your patients can somehow figure out what they mean.

Another approach to improving understanding is a visual one. There is growing support for the Universal Medication Schedule (UMS), which graphically represents 4 daily dosing times with the amount of medicine to be taken at each time. Some pharmacy management systems can now print UMS images on container labels and handouts.

Acting—As mentioned in other articles in this issue, medication adherence is multifaceted and can be affected by many issues such as financial resources, access to transportation to the pharmacy, etc. One of the nice benefits of the health literacy approach is that we can improve patients’ self-management skills and increase their awareness of the importance of each medicine. Including periodic reviews with patients, such as a medication therapy management session, can reinforce proper adherence behavior and identify other barriers to adherence.

There are measurement tools to score a patient’s health literacy levels, such as the Rapid Estimate of Adult Literacy in Medicine. These tools, however, are generally used only for research purposes and are impractical for daily use.

How Do You Target Low Health Literacy Patients?

The point of this approach is that you do not need to target any particular groups. This approach benefits everyone, and low health literacy patients the most.

As you can see, understanding is the cornerstone of patient adherence. Remember that half of your patients likely face obstacles to their ability to understand their instructions. Accommodating low healthy literacy provides a practical method for improving health outcomes for all your patients.

Dr. Charles Lee is founder and president of Polyglot Systems, Inc (Morrisville, NC), which he founded in 2001 with a mission to develop practical, affordable, multilanguage technology solutions to improve health care access and reduce disparities for underserved and limited English proficient patient populations. He is an internal medicine physician, an adjunct assistant professor at the UNC Eshelman School of Pharmacy, and a member of the FDA’s Risk Communication Advisory Committee.

References

• Institute of Medicine. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press; April 2004.
• Report of the Council on Scientific Affairs. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association. JAMA. 281(6):552-557.
• American Foundation for the Blind website. 2013. www.afb.org.