Kara L. Jacobson

Relationships between beliefs about medications and adherence

PURPOSE The relationships between beliefs about medications, health literacy, and self-reported medication adherence are examined. METHODS Patients from an inner-city hospital pharmacy completed an in-person, interviewer-assisted questionnaire that included the Morisky 8-item Medication Adherence Scale (MMAS-8), the Beliefs About Medicines Questionnaire (BMQ), and the Rapid Estimate of Adult Literacy in Medicine (REALM). Multivariable logistic regression was used to determine predictors of self-reported medication adherence as determined by the MMAS-8. Variables included in the model were summary scores from the BMQ, REALM, and patient or regimen characteristics that were significantly associated with the MMAS-8. RESULTS A majority of the 275 study participants were African-American (86.2%), were women (73.1%), and could read at less than a high school reading level (59.7%). The average age was 53.9 years. Approximately half of the patients (52.7%) reported low medication adherence (MMAS-8 score of >2). Multivariate analyses indicated several factors were associated with low self-reported adherence, including negative beliefs about medications, younger age, low medication self-efficacy, and hyperlipidemia. Health literacy was not independently associated with beliefs or adherence. CONCLUSION Patients who had negative beliefs about medications, who were <65 years of age, or who had low medication self-efficacy reported low medication adherence.

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 supports 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.

Developing Consumer-Centered, Nonprescription Drug Labeling: A Study in Acetaminophen

BACKGROUND In the U.S., acetaminophen overdose has surpassed viral hepatitis as the leading cause of acute liver failure, and misuse contributes to more than 30,000 hospitalizations annually. Half to two thirds of acetaminophen overdoses are unintentional, suggesting the root cause is likely poor understanding of medication labeling or failure to recognize the consequences of exceeding the recommended maximum daily dosage. PURPOSE Elicit subject feedback about active ingredient and dosing information on over-the-counter (OTC) acetaminophen and elicit feedback on proposed plain-language text and icons. METHODS Six focus groups, preceded by individual interviews, were conducted in April 2010 among 45 adults in two cities from two clinics and an adult basic education center. The individual interviews evaluated knowledge of OTC pain relievers, attention to product label information and literacy level while the group discussion elicited preference for label messages and icons. Analyses were conducted from April to June 2010. RESULTS Forty-four percent read at or below the 6th-grade level. Individual interviews revealed that <50% of participants routinely examine product label information. Only 31% know acetaminophen is in Tylenol®. The groups achieved consensus on a preferred icon for acetaminophen, desired explicit statement of potential liver damage in the warning against simultaneous use of acetaminophen products, and indicated preference for an icon and wording for maximum dose. CONCLUSIONS With the high prevalence of OTC use, a consumer-centered approach to developing icons and messages to promote awareness and safe use of acetaminophen could benefit consumers.

Effect of a Pharmacy-Based Health Literacy Intervention and Patient Characteristics on Medication Refill Adherence in an Urban Health System

BACKGROUND Limited health literacy is associated with poor understanding of medication instructions and may be related to medication adherence. OBJECTIVE To evaluate a 3-part intervention (automated telephone reminder calls to refill prescriptions, picture prescription card, and clear health communication training for pharmacists) intended to increase refill adherence through attention to health literacy. METHODS Three pharmacies that serve a primarily indigent, minority population served as the intervention sites, and one pharmacy served as the control site. To evaluate the impact of the 6-month intervention on medication adherence, pharmacy refill data were used to calculate the cumulative medication gap (CMG), in which values close to zero indicate better adherence. The primary measure of treatment effect was a comparison of the change in refill adherence within each group, from baseline to follow-up. RESULTS A total of 173 patients were enrolled in the intervention group and 102 patients in the control group. Medication adherence was significantly different between intervention (CMG = 0.25) and control (CMG = 0.18) groups at baseline (p = 0.004). Refill adherence in the intervention group improved slightly during follow-up (CMG = 0.23), while it worsened slightly in the control group (CMG = 0.21), but the change in adherence between intervention and control groups was not significantly different (p = 0.4). Between 80% and 90% of intervention participants indicated that receiving the picture prescription and phone call interventions helped them remember when and how to take their medications and refill their prescriptions. No patient characteristics, including health literacy, were consistently associated with adherence. CONCLUSIONS Implementation of a 3-part intervention—automated telephone reminders, picture prescription card, and pharmacist communication skills training—did not significantly improve refill adherence among inner-city patients. Further study should explore whether other aspects of medication management, such as dosing or adverse events, can be improved through these types of interventions, implemented either alone or in combination.

A Qualitative Evaluation of a Health Literacy Intervention to Improve Medication Adherence for Underserved Pharmacy Patients

Objective. To evaluate the implementation of a health literacy intervention to improve medication adherence among patients in an inner-city health system. Methods. Interviews with pharmacists and focus groups with pharmacy patients were conducted one month and six months after beginning the intervention. Patients and pharmacists described their experiences with the intervention, consisting of an automated telephone call reminder system, an illustrated medication schedule, and pharmacist training in clear health communication. Results. Despite initial technical problems, patients and pharmacists reported positive experiences. Pharmacists thought the intervention made counseling easier. Patients appreciated the design and portability of the illustrated medication schedule and found the reminder calls helpful as well. Conclusion. Successful health literacy interventions require tools that are easy to comprehend, accessible, and personalized to the special needs and interests of the target population. Moreover, providers must be well-trained, and adequate resources must be provided to assure the fidelity of the interventions implementation.

Development and Implementation of a Health Literacy Training Program for Medical Residents

Abstract Nearly 50 percent of Americans lack the literacy skills needed to function effectively in today’s health care environment. Experts recommend that health professionals be trained to better communicate with low-literacy patients, but few educational programs have been described. We developed a training program for medical residents that includes a videotaped standardized patient encounter, interactive small-group workshop, one-on-one feedback with a faculty member, and an individual behavioral prescription for improved communication. The program employs key principles of adult learning theory and evidence-based teaching approaches. Residents felt that the topic was relevant and that their communication skills benefited from the intervention. They enjoyed the teaching methods, particularly the individual feedback on their videotaped encounter. A qualitative process evaluation is provided to facilitate the teaching of similar programs elsewhere. Response to this curriculum indicates that residency appears to be a suitable time to raise awareness of health literacy and build appropriate communication skills.

Liquid Medication Errors and Dosing Tools: A Randomized Controlled Experiment

BACKGROUND AND OBJECTIVES: Poorly designed labels and packaging are key contributors to medication errors. To identify attributes of labels and dosing tools that could be improved, we examined the extent to which dosing error rates are affected by tool characteristics (ie, type, marking complexity) and discordance between units of measurement on labels and dosing tools; along with differences by health literacy and language. METHODS: Randomized controlled experiment in 3 urban pediatric clinics. English- or Spanish-speaking parents (n = 2110) of children ≤8 years old were randomly assigned to 1 of 5 study arms and given labels and dosing tools that varied in unit pairings. Each parent measured 9 doses of medication (3 amounts [2.5, 5, and 7.5 mL] and 3 tools [1 cup, 2 syringes (0.2- and 0.5-mL increments)]), in random order. Outcome assessed was dosing error (>20% deviation; large error defined as > 2 times the dose). RESULTS: A total of 84.4% of parents made ≥1 dosing error (21.0% ≥1 large error). More errors were seen with cups than syringes (adjusted odds ratio = 4.6; 95% confidence interval, 4.2–5.1) across health literacy and language groups (P < .001 for interactions), especially for smaller doses. No differences in error rates were seen between the 2 syringe types. Use of a teaspoon-only label (with a milliliter and teaspoon tool) was associated with more errors than when milliliter-only labels and tools were used (adjusted odds ratio = 1.2; 95% confidence interval, 1.01–1.4). CONCLUSIONS: Recommending oral syringes over cups, particularly for smaller doses, should be part of a comprehensive pediatric labeling and dosing strategy to reduce medication errors.

Literacy disparities in patient access and health-related use of Internet and mobile technologies

Age and race‐related disparities in technology use have been well documented, but less is known about how health literacy influences technology access and use.

A Randomized Prospective Trial of a Worksite Intervention Program to Increase Physical Activity

Purpose. To evaluate the effectiveness of addressing multiple barriers to physical activity (PA) using interventions at the workplace. Design. The Physical Activity and Lifestyle Study used a randomized controlled trial in which 60 university departments were randomized into five groups. Setting. Large Southeastern university. Subjects. Physically inactive nonfaculty employees in the participating departments (n = 410) were interviewed five times over 9 months, with 82% completing all surveys. Intervention. Departments were randomly assigned to (1) control, (2) gym membership, (3) gym + PA education, (4) gym + time during the workday, and (5) gym + education + time. Measures. PA intensity and quantity were measured using the 7-day Physical Activity Recall instrument, with PA then classified as the number of days meeting Centers for Disease Control and Prevention guidelines. Analysis. The outcome was modeled with generalized linear mixed model methodology. Results. There was no significant improvement when a group received gym alone compared to the control (Rate Ratio [RR]) 1.22 [.90, 1.67]). However, gym + education, gym + time, and gym + education + time were significantly better than the control (RR 1.51 [1.15, 1.98], RR 1.46 [1.13, 1.88], RR 1.28 [1.01, 1.62]), with improvements sustained over the 9 months. Conclusion. Among sedentary adults who had access to indoor exercise facilities, addressing environmental and cognitive barriers simultaneously (i.e., time and education) did not encourage more activity than addressing either barrier alone.

Comparison of Handwritten and Electronically Generated Prescription Drug Instructions

1. Horn JR, Hansten PD, Chan L-N. Proposal for a new tool to evaluate drug interaction cases. Ann Pharmacother 2007;41:674-80. Epub 27 Mar 2007. DOI 10.1345/aph.1H423 2. Taylor JR, Wilt VM. Probable antagonism of warfarin by green tea. Ann Pharmacother 1999;33:426-8. DOI 10.1345/aph.18238 3. Natural medicines comprehensive database. Black tea. www. naturaldatabase.com (accessed 2008 Jul 30). 4. Medline Plus. Black tea (Camellia sinensis). www.nlm.nih.gov/medlineplus/druginfo/natural/patient-black_tea.html (accessed 2008 Jun 26). 5. Steptoe A, Gibson EL, Vuononvirta R, et al. The effects of chronic tea intake on platelet activation and inflammation; a double-blind placebo controlled trial. Atherosclerosis 2007;193:277-82. DOI 10.1016/j.atherosclerosis.2006.08.054