Health literacy: A barrier to pharmacist–patient communication and medication adherence

doi:10.1331/JAPhA.2009.07075

Journal of the American Pharmacists Association

Volume 49, Issue 5, September–October 2009, Pages e132-e149

https://doi.org/10.1331/JAPhA.2009.07075 Get rights and content

Abstract

Objectives

To present a summary of the existing literature on medication nonadherence, health literacy, and use of written patient information in health care and pharmacy in particular.

Data sources

Searches of Medline, PubMed, and International Pharmaceutical Abstracts databases were conducted using one or more of the following terms adherence/nonadherence, compliance/noncompliance, printed/written information, literacy, patient education, communication, and health literacy. These terms were combined with the following search terms: drug information, readability, medication/drug, patient, pharmacy/pharmacist, and prescription. References of pertinent articles were hand searched to retrieve additional articles.

Data extraction

By the author.

Data synthesis

Articles were grouped and summarized into three broad categories (nonadherence, health literacy, and communicating health information to patients), with an emphasis on the use of written patient information in health care and pharmacy practice in particular. The complexities inherent in nonadherence behavior, health literacy, and patient education are summarized, and suggestions for enhancing medication adherence, especially for patients with low health literacy skills, are provided.

Conclusion

The health literacy skills of American adults have not changed considerably during the previous decade. This makes use of written patient medication information in pharmacy practice problematic for some patients. Limited health literacy has been associated with poorer health, medication nonadherence, medication errors, higher medical expenses, and increased hospitalization. A need exists for identifying patients with limited health literacy and tailoring medication counseling to their needs.

Section snippets

Objectives

The goal of this article is to present a summary of the existing literature on health literacy and its effect on medication nonadherence and pharmacist–patient communications and the use of written patient information in health care and pharmacy.

Search strategy

Potentially relevant articles were identified by searching the Medline, PubMed, and International Pharmaceutical Abstracts databases using the following terms: adherence/nonadherence, compliance/noncompliance, printed/written information, literacy, patient education, communication, and health literacy. These terms were combined with the following search terms: drug information, readability, medication/drug, patient, pharmacy/pharmacist, and prescription. References of pertinent articles were

Medication adherence

Compliance was defined more than 2 decades ago as “the extent to which a person's behavior (in terms of taking medications, following diets or executing other life-style changes) coincides with medical or health advice.”³ This term was later criticized for implying paternalism. The terms adherence and concordance have replaced compliance. Adherence is favored because of its connotation that the patient–provider relationship is based on respect and collaboration.²⁷ It also includes the patient

Health literacy

Healthy People 2010 defines health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”⁵⁴ Thus, health literacy relates to both the cognitive and functional skills used to make health-related decisions.⁵⁵ This definition also implies that literacy goes beyond the ability to read a sentence to the ability to comprehend the written word. Health literacy includes

Effectively communicating health information

Most of the health education information that is provided to patients, both oral instructions and written information, is presented in a format that is too complex for the average person to understand.²^,⁵⁸^,65., 66., 67. This communication mismatch is one of the causes of nonadherence.²^,¹⁰^,⁶⁸^,⁶⁹ Approximately one-third of all patients and two-thirds of physicians know someone who has had health problems because they did not understand how to take a prescription medication correctly.⁷⁰ Inadequate

Implications for pharmacy practice

Substantial evidence indicates that inadequate health literacy adversely affects adherence behavior, patients' knowledge, self-care for chronic diseases, and health care costs.²⁵^,¹¹⁹^,¹²⁰ The IOM report To Err Is Human⁶⁸ noted that management of complex medication therapies, especially in elderly patients, is extremely difficult and requires special attention to the ability of the patient to understand and remember the amount and timing of a dose, as well as behavioral modifications required by

Looking ahead: Pharmacist–patient interactions

Health care delivery continues to shift from inpatient to outpatient settings, and the practice of quality control over medication use is becoming more the responsibility of the patient and less the responsibility of the provider.¹⁰⁹ These trends indicate the importance of the pharmacist–patient interaction in ensuring that patients have the skill and knowledge needed to perform self-care medication-taking behaviors. Pharmacists have the essential technical knowledge for assisting patients with

Conclusion

Although pharmacy-specific recommendations are still lacking for the most part, the need for health literacy education for pharmacists and students remains high. Such education should promote awareness of how to recognize patients with low literacy skills and provide strategies to enhance understanding and adherence in this population. Although the information provided in this article is not exhaustive or comprehensive, it can assist pharmacists in their efforts to communicate more effectively

Assessment Questions

Instructions: The assessment test for this activity must be taken online; please see “CPE processing” below for further instructions. There is only one correct answer to each question. This CPE will be available at www.pharmacist.com no later than August 31, 2009.

1.
What percent of patients typically take medications as prescribed according to the World Health Organization?
- a.
  10%
- b.
  20%
- c.
  30%
- d.
  40%
- e.
  50%
2.
What percent of patients are adherent with taking prescribed medications during a 1-year period?
- a.
  10–20%
- b.
  30–40%
- c.

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Cited by (169)

Message frame and health literacy: Strategies to improve adherence to antihypertensive medications
2023, Research in Social and Administrative Pharmacy
Hypertension and prehypertension is prevalent in about half of the total world population. Experts recommend comprehensive medical treatment for people with underlying diseases or at risk for metabolic syndrome. However, previous studies have found that approximately half of all patients with hypertension stopped taking antihypertensive medication within a year, and this phenomenon was closely related to the low perceived benefit and outcome expectation of taking behavior.
As the initial perception of medication is greatly influenced by the medication message, this study explored the effect of the gain-loss framing of the message of adherence to antihypertensives. Furthermore, the study analyzed the interaction between health literacy and involvement, which is a characteristic of the message recipient, and the message frame and examined how the message strategy should differ according to individual factors.
The quasi-experiment via an online survey was conducted from August 9 to 11, 2021. Participants who had the potential for hypertension but had not yet been diagnosed were selected through screening questions. A total of 1200 participants were randomly assigned to each frame group. Data analysis was conducted using descriptive statistics, analysis of covariance for analysis of main effects and interaction effects between variables, and Bonferroni post-hoc for multiple analyses.
Regarding medical adherence intention, the frame did not show a main effect, whereas individual factors showed a main effect. An interaction effect of frame and individual factors were found. Specifically, in the group with low health literacy or low involvement, a significant gain frame advantage effect was observed.
This study verified the relationship between medication messages and behavior and provides insight into tailoring messages to antihypertensive adherence; it found that individuals’ health literacy and involvement must be considered in health communication message strategies.
Factors associated with medication adherence among people living with COPD: Pharmacists' perspectives
2021, Exploratory Research in Clinical and Social Pharmacy
While medication is an integral part of the effective management of COPD, more than 50% of people living with COPD do not adhere to their prescribed medications. The drivers underpinning this observed behaviour are poorly understood. As pharmacists generally have the final interaction with patients prior to their use of medications, their perspectives may offer insights about patients' medication use that may improve our understanding of this complex issue.
This study explored pharmacists' experiences of providing care for patients living with COPD to gain insight about factors that impact their medication-taking behaviour.
Fourteen pharmacists who worked in practice settings across the South-East Queensland region of Australia participated in interviews between March 2019 and January 2020. Interviews were audio-recorded, transcribed verbatim, and thematically analysed.
Two overarching themes were identified which modulated medication-taking behaviour. Barriers comprised patient-related factors including, financial constraints, poor inhaler technique, and inaccurate beliefs; alongside pharmacist-related factors such as a lack of COPD-specific training and time constraints. Factors that promote adherence included patient education and monitoring and collaborative relationships between key stakeholders.
Medication non-adherence is common. While pharmacists expressed a desire to better support their patients, practical strategies to overcome the challenges that they face in clinical settings are lacking. Future research should focus on exploring ways to engage patients at the pharmacy level thereby enhancing the provision of services that would optimise medication adherence.
Analysis of Identified risks in the release of over-the-counter medicines to Teenagers
2024, Research Journal of Pharmacy and Technology
“Nevertheless, it is still painful”: Use of Over-the-Counter analgesics, pain, stress, and HRQOL in Norwegian adolescents: a cross sectional study
2023, Research Square
Examining the relationship between health literacy and quality of life: evidence from older people admitted to the hospital
2023, BMC Geriatrics
Evaluation of the Rational Drug Use (RDU) literacy among undergraduate students
2023, Pharmacy Practice

View all citing articles on Scopus

: Continuing pharmacy education (CPE) credits: See learning objectives below and assessment questions at the end of this article, which is ACPE universal activity number 202-000-09-219-H04-P in APhA's educational offerings. To take the CPE test for this article online, go to www.pharmacist.com/education, and follow the links to the APhA CPE Center.

: Disclosure: The author and APhA's editorial staff declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria.

View full text

ReviewsHealth literacy: A barrier to pharmacist–patient communication and medication adherence

Abstract

Objectives

Data sources

Data extraction

Data synthesis

Conclusion

Section snippets

Objectives

Search strategy

Medication adherence

Health literacy

Effectively communicating health information

Implications for pharmacy practice

Looking ahead: Pharmacist–patient interactions

Conclusion

Assessment Questions

J Am Pharm Assoc.

Patient Educ Couns.

Chest.

J Am Pharm Assoc.

Clin Ther.

Transplant Proc.

J Clin Epidemiol.

Patient Educ Couns.

Am J Prev Med.

J Nurse Pract.

J Am Pharm Assoc.

Patient Educ Couns.

J Am Pharm Assoc.

Soc Sci Med.

Soc Sci Med.

Patient Educ Couns.

Patient Educ Couns.

J Am Pharm Assoc.

Use of pictorial aids in medication instructions: a review of the literature

Am J Health Syst Pharm.

Introduction

Compliance: definitions and key issues

J Clin Psychiatry.

The health literacy of America's adults: results from the 2003 National Assessment of Adult Literacy (NCES 2006-483).

Taking your medicine: relational steps to improving patient compliance

Health Marketing Q.

Medication non-adherence: finding solutions to a costly medical problem

Drug Benefits Trends.

Compliance with drug therapy: new answers to an old question

Nephrol Dial Transplant.

Predictors of medication self-management skill in a low-literacy population

J Gen Intern Med.

Enhancing patient adherence to medical recommendations

JAMA.

American Pharmacists Association. Enhancing patient adherence: proceedings of the Pinnacle Roundtable Discussion

Highlights News Letter.

Treatment nonadherence: causes and potential solutions

J Am Psychiatr Nurses Assoc.

Improving comprehension for cancer patients with low literacy skills: strategies for clinicians

CA Cancer J Clin.

Relationship of functional health literacy to patients’ knowledge of their chronic disease: a study of patients with hypertension and diabetes

Arch Intern Med.

Association of health literacy with diabetes outcomes

JAMA.

A multivariate analysis of factors associated with depression: evaluating the role of health literacy as a potential contributor

Arch Intern Med.

Health status of illiterate adults: relation between literacy and health status among persons with low literacy skills

J Am Board Fam Pract.

Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence

Arch Intern Med.

Functional health literacy and the risk of hospital admission among Medicare managed care enrollees

Am J Public Health.

Health literacy and the risk of hospital admission

J Gen Intern Med.

Strömberg A. Patient-related factors of compliance in heart failure: some new insights into an old problem

Eur Heart J.

Adherence to long term therapies: evidence for action.

Comply with us: improving medication adherence

J Pharm Pract.

Primary medication adherence in a rural population: the role of the patient-physician relationship and satisfaction with care

J Am Board Fam Med.

Adherence to medication

N Engl J Med.

Reviews
Health literacy: A barrier to pharmacist–patient communication and medication adherence