A health literacy pilot intervention to improve medication adherence using Meducation technology

Objective

To determine whether antihypertensive medication adherence could improve using a Meducation^® technology health literacy intervention.

Methods

We conducted a six-month feasibility study among patients with cardiovascular disease (CVD) risk factors receiving care from hospital-based primary care clinics. All patients received a personalized Meducation^® calendar listing CVD-related medications. We evaluated changes in medication adherence and clinical outcomes at six months.

Results

There was a 42% enrollment rate (n = 23). Forty percent had low health literacy, defined as less than 9th grade reading level. At three months, self-reported medication adherence improved. At six months, medication possession ratio improved 3.2%. Also, at six months there were decreases in patients’ average systolic blood pressure (0.5 mmHg), diastolic blood pressure (1.5 mmHg), and body weight (3.6 pounds) (p > 0.05).

Conclusions

A health literacy intervention may be a feasible mechanism to improve cardiovascular-related medication adherence and outcomes.

Practice implications

Health literacy interventions may improve adherence while requiring relatively few resources to implement.     

Association of age, health literacy, and medication management strategies with cardiovascular medication adherence

Objective

To examine patients’ use of medication management strategies (e.g., reminders, pill boxes), and to determine how their use influences the relationship between patient characteristics and medication adherence.

Methods

Retrospective and cross-sectional study of 434 patients with coronary heart disease, examining both refill adherence and self-reported adherence.

Results

The most common strategy for managing refills was seeing a near empty pill bottle (89.9%), and for managing daily medications, it was associating medications with daily events (80.4%). Age < 65 (OR = 1.7), as well as marginal (OR = 2.0) or inadequate health literacy (OR = 1.9), was independently associated with low refill adherence. Patients <65 also had lower self-reported adherence (OR = 1.8). Adjustment for use of medication management strategies did not substantially change these relationships. Reliance on reminders from friends or family to take medications, or waiting to refill a medicine only when the bottle was near empty, each were associated with 3-fold greater odds of non-adherence.

Conclusion

Age <65 and marginal or inadequate health literacy were independently associated with medication non-adherence. Use of medication management strategies did not explain these relationships.

Practice implications

The strategies which patients report using to assist with managing medication refills and daily medication use may be ineffective.     

Caregiver health literacy and adherence to a daily multi-vitamin with iron regimen in infants

Objective

To determine whether or not limited caregiver health literacy is associated with adherence to a daily multi-vitamin with iron regimen in infants.

Methods

110 caregiver/infant dyads were enrolled in a prospective study to assess the relationship between caregiver health literacy and adherence to a daily multi-vitamin with iron regimen for infants. Households were contacted biweekly over a 3-month period. Adherence was based upon caregiver report. High adherence, our primary outcome, was defined as the administration of the multi-vitamin with iron on 5–7 days over the past week.

Results

As measured by the Short Test of Functional Health Literacy in Adults (S-TOFHLA), 18% of caregivers had limited health literacy skills. Caregivers with limited health literacy skills were more likely to have higher adherence than caregivers with adequate health literacy, after adjusting for a number of possible confounding variables (AOR = 2.13; 95% 1.20–3.78).

Conclusion

Caregivers with limited health literacy were twice as likely to report high adherence to a daily multi-vitamin with iron regimen in infants as caregivers with adequate health literacy in adjusted analysis.

Practice implications

Health literacy may exert a differential influence on adherence depending upon the complexity of the desired health behavior.     

Does social support help limited-literacy patients with medication adherence?: A mixed methods study of patients in the Pharmacy Intervention for Limited Literacy (PILL) Study

Objective

To explore whether social support helps patients with limited health literacy adhere to their medication regimens.

Methods

We interviewed 275 pharmacy patients and assessed social support's influence on medication adherence for those with limited vs. adequate health literacy. We talked with patients (n = 26) and pharmacists (n = 7) to explore possible explanations for the quantitative findings.

Results

Social support was associated with better medication adherence for patients with adequate health literacy but not those with limited health literacy (p < 0.05). When individual subscales for social support were analyzed, having a trusted confidant was the only type of social support associated with better medication adherence for limited-literacy patients (p < 0.05). Comments from patients and pharmacists suggest that limited-literacy patients were less likely to ask the pharmacists questions and infrequently brought relatives with them to the pharmacy.

Conclusion

Unless they have a trusted confidant, limited-literacy patients might be reluctant to ask others for the kind of help needed to take their medicines correctly.

Practice implications

Pharmacists need training to increase their awareness of limited health literacy and to communicate effectively with all patients, regardless of their literacy skills. To succeed, pharmacists also need the support of the health care systems where they work.     

Health literacy and physical and psychological wellbeing in Japanese adults

Objective

To determine the prevalence of low health literacy and investigate the relationship between low health literacy and physical and psychological wellbeing in the Japanese general population.

Methods

A web-based cross-sectional survey was conducted in a national sample of Japanese adults. Health literacy was measured by self-report using the validated single-item screening question, “How confident are you filling out forms by yourself?” Wellbeing was measured with the physical and psychological domains of the World Health Organization Quality of Life Assessment-BREF. Effect sizes were computed by dividing the mean difference in scores by the standard deviation of the scores of all participants.

Results

In 1040 adult enrollees (mean age, 57-year-old; women, 52%), there were 161 (15.5%; 95% confidence interval [CI], 13.3–17.7%) with low health literacy. Individuals with low health literacy reported lower physical wellbeing (60.6 vs. 71.7, p < 0.001) and psychological wellbeing (59.7 vs. 68.3, p < 0.001) compared with those with adequate health literacy. After adjusting for sociodemographic characteristics, health risk behaviors and chronic conditions, these differences were still significant (physical wellbeing, p < 0.001; psychological wellbeing, p < 0.001). The effect sizes of the difference of scores were moderate for physical wellbeing (−0.55) and also for psychological wellbeing (−0.44).

Conclusion

The prevalence of self-reported low health literacy in Japanese adults is substantial and it is independently associated with poorer physical and mental wellbeing.

Practice implications

Efforts to monitor health literacy and to evaluate causal pathways to poor wellbeing should be encouraged in the Japanese population.     

Functional health literacy mediates the relationship between socio-economic status,perceptions and lifestyle behaviors related to cancer risk in an Australian population

Objective

To determine if functional health literacy (FHL) mediates the relationship between socio-economic status, and perception of the risk of lifestyle behaviors for cancer.

Methods

Cross-sectional, random population survey, 2824 people aged ≥15 years, September–October 2008, included newest vital sign measure of FHL.

Results

Less than adequate FHL occurred in 45.1%. People who perceived behavioral factors (smoking, diet, obesity, alcohol, physical activity) to be not important, or did not know if they were important cancer risks, were more likely to have inadequate FHL. In a logistic regression model adjusted for age, gender, education, income, occupation, country of birth and area of residence, inadequate FHL was associated with 2–3 (OR = 1.9; 95% CI: 1.2–3.0) and 4 or more self-reported lifestyle risk factors (OR = 2.8; 95% CI: 1.6–5.0). In a structural equation model of the relationship of socio-economic status, perceptions of risk and behaviors there was significant mediation effect of FHL on the path from SES to health perceptions, estimated 29.4% of the total effect.

Conclusion

A specific focus on the literacy demands made on individuals from health promotion and materials with a view to improving health communication is indicated.

Practice implications

Health literacy is important for health promotion.     

International application of health literacy measures: Adaptation and validation of the newest vital sign in The Netherlands

Objective

The newest vital sign assesses individual reading and numeracy skills. The aim of this study was to create a Dutch version (NVS-D) and to assess its feasibility, reliability, and validity in The Netherlands.

Methods

We performed a qualitative study among experts (n = 27) and patients (n = 30) to develop the NVS-D and to assess its feasibility. For validation, we conducted a quantitative survey (n = 329). Reliability was assessed by Cronbach's alpha. Construct validity was examined by analyzing association patterns. Receiver operating characteristic (ROC) curves determined optimal cut-off scores.

Results

Cronbach's alpha was 0.76. In accordance with a priori hypotheses we found strong associations between NVS-D, general vocabulary, prose literacy and objective health literacy, and weaker associations between NVS-D and subjective health literacy. A score of ≥4 out of 6 best distinguished individuals with adequate versus inadequate health literacy.

Conclusion

The results suggest that the NVS-D is a reliable and valid tool that allows international comparable health literacy research in The Netherlands.

Practice implications

The NVS-D can be applied in research on the role of health literacy in health and health care, and the development of interventions. The methods can be applied in cross-cultural adaptation of health literacy measures in other countries.     

A text messaging intervention to promote medication adherence for patients with coronary heart disease: A randomized controlled trial

Objective

Pharmacologic treatment for secondary prevention of coronary heart disease (CHD) is critical to prevent adverse clinical outcomes. In a randomized controlled trial, we compared antiplatelet and statin adherence among patients with CHD who received: (1) text messages (TM) for medication reminders and education, (2) educational TM only, or (3) No TM.

Methods

A mobile health intervention delivered customized TM for 30 days. We assessed and analyzed medication adherence with electronic monitoring devices [Medication Event Monitoring System (MEMS)] by one-way ANOVA and Welch tests, two-way TM response rates by t-tests, and self-reported adherence (Morisky Medication Adherence Scale) by Repeated Measures ANOVA.

Results

Among 90 patients (76% male, mean age 59.2 years), MEMS revealed patients who received TM for antiplatelets had a higher percentage of correct doses taken (p = 0.02), percentage number of doses taken (p = 0.01), and percentage of prescribed doses taken on schedule (p = 0.01). TM response rates were higher for antiplatelets than statins (p = 0.005). Self-reported adherence revealed no significant differences among groups.

Conclusion

TM increased adherence to antiplatelet therapy demonstrated by MEMS and TM responses.

Practice implications

Feasibility and high satisfaction were established. Mobile health interventions show promise in promoting medication adherence.     

The relationship between health literacy and knowledge improvement after a multimedia type 2 diabetes education program

Objective

Multimedia diabetes education programs (MDEP) have the potential to improve communication and education of those with low health literacy. We examined the effect of a MDEP targeted to patients with low literacy on knowledge and assessed the association between literacy and knowledge improvement.

Methods

We showed the MDEP to 190 patients recruited from clinics at a federally qualified health center and an academic health center. We measured diabetes knowledge before and after viewing the MDEP.

Results

Seventy-nine percent of patients had adequate literacy, 13% marginal, and 8% inadequate literacy. Patients across all literacy levels had significant increases in knowledge scores after viewing the MDEP (p-value < 0.001). Patients with inadequate literacy learned significantly less after the MDEP (adjusted beta-coefficient = −2.3, SE = 0.70) compared to those with adequate literacy.

Conclusions

A MDEP designed for those with low literacy significantly increased diabetes knowledge across literacy levels. However, the MDEP did not overcome the learning gap between patients with low and high literacy.

Practice implications

A literacy appropriate MDEP may be an effective way to teach patients about diabetes. Combining the MDEP with other education methods may improve comprehension and learning among those with low literacy. Research is needed to identify which characteristics of low-literate patients influence the ability to learn health information. Identifying these factors and incorporating solutions into a diabetes education intervention may help bridge the learning gap related to literacy status.     

Patient trust in physicians and adoption of lifestyle behaviors to control high blood pressure

Objective

To assess the relationship between patients’ trust in their physician and self-reported adoption of lifestyle modification behaviors and medication adherence for control of hypertension.

Methods

Longitudinal analysis of data from a randomized controlled trial of interventions to enhance hypertensive patients’ adherence to medications and recommended lifestyle modifications. Two hundred patients were seen by 41 physicians at 14 urban primary care practices in Baltimore, Maryland, and followed for 12 months.

Results

Seventy percent of patients reported complete trust in their physician. In adjusted analyses, patients with complete trust had higher odds of reporting that they were trying to lose weight (OR = 2.27, 95% CI = 1.38–3.74) than did patients with less than complete trust in their physician. Though not statistically significant, the odds of reporting trying to cut back on salt and engaging in regular exercise were greater in patients with complete trust. We observed no association for reports of medication adherence.

Conclusion

Trust in one's physician predicts attempts to lose weight among patients with hypertension, and may contribute to attempts to reduce salt and increase exercise.

Practice implications

Strengthening patient–physician relationships through efforts to enhance trust may be a promising strategy to enhance patients’ engagement in healthy lifestyle behaviors for hypertension.     

The association of health literacy with illness and medication beliefs among older adults with asthma

Objective

Suboptimal health literacy (HL) and asthma beliefs are associated with poor asthma self-management and outcomes. We tested the hypothesis that low HL is associated with inaccurate beliefs.

Methods

Asthmatics ≥60 were recruited from hospital and community practices in New York, NY and Chicago, IL (n = 420). HL was measured with the Short Test of Functional Health Literacy in Adults; validated instruments derived from the self regulation model were used to assess beliefs. The association of beliefs with HL was evaluated with multivariate models.

Results

Thirty-six percent of patients had low HL; 54% believed they only have asthma when symptoms are present, 29% believed they will not always have asthma and 20% believed that their doctor can cure asthma. HL was associated with beliefs of not having asthma all the time and that asthma can be cured (OR: 1.84, 95% CI: 1.2–2.82; OR: 2.22, 95% CI: 1.29–3.82, respectively). Patients with low HL were also more likely to be concerned about medication use (β = 0.92, p = .05), despite recognizing their necessity (β = −1.36, p = .01).

Conclusions

Older asthmatics with low HL endorse erroneous asthma beliefs.

Practice implications

Health communications for improving self-management behaviors in asthma should employ both health literacy-appropriate strategies and messages to counter illness-related misconceptions.     

Can lay health workers promote better medical self-management by persons living with HIV? An evaluation of the Positive Choices program

Objective

To evaluate Positive Choices (PC), a program that employed lay health workers to motivate antiretroviral adherence among persons living with HIV with coverage from Indiana's high-risk insurance pool.

Methods

Four hundred and forty nine participants living in the greater Indianapolis area were randomly allocated to treatment (n = 91) or control (n = 358) groups and followed for one year.

Results

Compared to control subjects, PC subjects were more likely to adhere to HIV medications (medication possession ratio adherence ≥0.95, OR = 1.83, p = 0.046), and to achieve undetectable viral load (<50 copies/mL, OR = 2.01, p = 0.011) in the 12 months following introduction of PC. There were no significant differences observed between groups in any of self-reported health status indicators.

Conclusion

Estimates suggest that PC clients were 16% more likely to have undetectable viral loads than clients in standard care. The incremental program cost was approximately $10,000 for each additional person who achieved an undetectable viral load.

Practice implications

As persons living with HIV experience greater longevity and healthcare reform expands coverage to these high-risk populations, greater demands will be placed on the HIV-care workforce. Results suggest lay health workers may serve as effective adjuncts to professional care providers.     

Addressing health literacy through clear health communication: A training program for internal medicine residents

Objective

To develop, pilot, and test the effectiveness of a clear health communication curriculum to improve resident knowledge, attitudes, and skills regarding health literacy.

Methods

Thirty-one internal medicine residents participated in a small group curriculum that included didactic teaching, practice with a standardized patient, and individualized feedback on videotaped encounters with real patients. Outcomes were assessed using a pre-post survey and a communication skills checklist.

Results

Mean knowledge scores increased significantly from 60.3% to 77.6% (p < 0.001). Residents also reported increased familiarity with the concept of health literacy (mean response 3.2 vs. 4.5 on a 5 point scale), importance placed on health literacy (4.2 vs. 4.9), frequency of considering health literacy in patient care (3.3 vs. 4.0), and confidence in communicating with low literacy patients (3.3 vs. 4.1) (all p < 0.001). Use of plain language increased significantly from 33% to 86% (p = 0.023). There were nonsignificant increases in the use of teach-back (0–36%, p = 0.116) and encouraging questions (0–14%, p = 0.502).

Conclusion

Training in clear health communication improves resident knowledge, attitudes, and skills regarding health literacy.

Practice implications

The increased use of clear health communication techniques can significantly improve the care and outcomes of vulnerable patients with limited health literacy.     

Evaluation of the effect of motivational interviewing counselling on hypertension care

Objective

This study tests the effectiveness of motivational interviewing compared with the usual care for Chinese hypertensive patients.

Methods

A randomised controlled trial was used. One hundred and twenty eligible participants were randomly assigned to either the control group (usual care group) or the intervention group (motivational interviewing group).

Results

The results of this study demonstrated that the total scores and the mean scores for each dimension of the adherence questionnaire were increased in the intervention group (P < 0.05), and the systolic blood pressure and diastolic blood pressure of the hypertensive patients greatly decreased in the intervention group during the six months of the motivational interviewing counselling (P < 0.05).

Conclusion

The application of motivational interviewing for hypertensive patients is a promising approach for sustaining the clinical benefits of adherence behaviour.

Practice implications

Motivational interviewing should be provided to hypertensive patients at hospitals and community health centres to assist patients in controlling their BP and to enhance treatment adherence. A series of training courses on the motivational interviewing technique should be provided to nurses.     

Effect of cognitive dysfunction on the relationship between age and health literacy

Objective

Age is generally an inverse predictor of health literacy. However, the role of cognitive dysfunction among older adults in this relationship is not understood.

Methods

We conducted a cross-sectional survey of 446 adult patients in a large urban academic level one trauma center, assessing health literacy and cognitive dysfunction.

Results

Removing older patients (60 years of age and older) who screened positive for cognitive dysfunction attenuated the relationship between age and health literacy (r = −0.16, p = 0.001 vs. r = −0.35, p < 0.0001). Older patients screening positive for cognitive dysfunction had significantly lower health literacy than older patients screening negative and patients less than 60 years; health literacy scores did not generally differ significantly between the latter groups.

Conclusion

Much of the relationship between age and health literacy was driven by cognitive dysfunction among a subset of older adults.

Practice implications

Our findings suggest that older patients with cognitive dysfunction have the greatest need for health literacy interventions.     

Education,literacy, and health: Mediating effects on hypertension knowledge and control

Objective

To determine whether literacy mediates the association between education, hypertension knowledge and control.

Methods

In-person interviews with a literacy assessment and chart review were conducted with 330 hypertensive patients from six primary care safety net clinics. Mediational analysis was used to test the role of literacy skills in explaining the relationship between education and hypertension knowledge and control.

Results

In multivariate analyses that did not make an adjustment for the other variable, both lower educational attainment and more limited literacy were found to be significant independent predictors of poorer hypertension knowledge and control. When literacy was entered into models that included education only, the association between education and knowledge was fully attenuated and no longer significant (Grades 1–8: β = −0.30, 95% CI = −1.44–0.83), while the relationship between education and blood pressure control was only minimally reduced (AOR 2.46, 95% CI 2.10–2.88). More limited literacy skills also was associated with hypertension control in the final model (AOR 2.68, 95% CI 1.54–4.70).

Conclusion

Patient literacy mediated the relationship between education and hypertension knowledge. Literacy was a significant independent predictor of blood pressure control, but only minimally explained the relationship between education and blood pressure.

Practice implications

Health literacy is critical to the design of educational tools to improve knowledge acquisition. However, in order to impact health outcome, future health literacy studies should also address other psychosocial factors that impact motivation and capability to manage disease.     

Time perspective and medication adherence among individuals with hypertension or diabetes mellitus

Objective

The study determined if time perspective was associated with medication adherence among people with hypertension and diabetes.

Methods

Using the Health Beliefs Model, we used path analysis to test direct and indirect effects of time perspective and health beliefs on adherence among 178 people who participated in a community-based survey near Washington, D.C. We measured three time perspectives (future, present fatalistic, and present hedonistic) with the Zimbardo Time Perspective Inventory and medication adherence by self-report.

Results

The total model demonstrated a good fit (RMSEA = 0.17, 90% CI [0.10, 0.28], p = 0.003; comparative fit index = 0.91). Future time perspective and age showed direct effects on increased medication adherence; an increase by a single unit in future time perspective was associated with a 0.32 standard deviation increase in reported adherence. There were no significant indirect effects of time perspective with reported medication adherence through health beliefs.

Conclusion

The findings provide the first evidence that time perspective plays an under-recognized role as a psychological motivator in medication adherence.

Practice implications

Patient counseling for medication adherence may be enhanced if clinicians incorporate consideration of the patient's time perspective.     

Development and validation of the General Health Numeracy Test (GHNT)

Objective

Because existing numeracy measures may not optimally assess ‘health numeracy’, we developed and validated the General Health Numeracy Test (GHNT).

Methods

An iterative pilot testing process produced 21 GHNT items that were administered to 205 patients along with validated measures of health literacy, objective numeracy, subjective numeracy, and medication understanding and medication adherence. We assessed the GHNT's internal consistency reliability, construct validity, and explored its predictive validity.

Results

On average, participants were 55.0 ± 13.8 years old, 64.9% female, 29.8% non-White, and 51.7% had incomes ≤$39 K with 14.4 ± 2.9 years of education. Psychometric testing produced a 6-item version (GHNT-6). The GHNT-21 and GHNT-6 had acceptable-good internal consistency reliability (KR-20 = 0.87 vs. 0.77, respectively). Both versions were positively associated with income, education, health literacy, objective numeracy, and subjective numeracy (all p < .001). Furthermore, both versions were associated with participants’ understanding of their medications and medication adherence in unadjusted analyses, but only the GHNT-21 was associated with medication understanding in adjusted analyses.

Conclusions

The GHNT-21 and GHNT-6 are reliable and valid tools for assessing health numeracy.

Practice implications

Brief, reliable, and valid assessments of health numeracy can assess a patient's numeracy status, and may ultimately help providers and educators tailor education to patients.     

Literacy-appropriate educational materials and brief counseling improve diabetes self-management

Objective

In this pilot study, we evaluated the impact of providing patients with a literacy-appropriate diabetes education guide accompanied by brief counseling designed for use in primary care.

Methods

We provided the Living with Diabetes guide and brief behavior change counseling to 250 English and Spanish speaking patients with type 2 diabetes. Counseling sessions using collaborative goal setting occurred at baseline and by telephone at 2 and 4 weeks. We measured patients’ activation, self-efficacy, diabetes distress, knowledge, and self-care at baseline and 3-month follow-up.

Results

Statistically significant (p ≤ 0.001) and clinically important (effect sizes = 0.29–0.42) improvements were observed in participants’ activation, self-efficacy, diabetes-related distress, self-reported behaviors, and knowledge. Improvements were similar across literacy levels. Spanish speakers experienced both greater improvement in diabetes-related distress and less improvement in self-efficacy levels than English speakers.

Conclusion

A diabetes self-management support package combining literacy-appropriate patient education materials with brief counseling suitable for use in primary care resulted in important short-term health-related psychological and behavioral changes across literacy levels.

Practice implications

Coupling literacy-appropriate education materials with brief counseling in primary care settings may be an effective and efficient strategy for imparting skills necessary for diabetes self-management.