Background Health literacy is the ability to obtain, interpret and use health information. Low rates of health literacy in Australia have been suggested, but no validated measure exists.
Objective To explore health literacy competencies in a sample of community pharmacy consumers.
Design Structured interviews were undertaken by a team of researchers during August, 2009. The instrument was derived from available literature, measuring aspects of functional, interactive and critical health literacy regarding use of medicines.
Setting and participants Twelve community pharmacies in the Brisbane region, Australia.
Results Six hundred and forty‐seven consumers participated; 64% were women. A wide distribution of ages was evident. English was the first language of 89% of respondents. More than half of the sample (55%), predominantly aged 26–45 years, was tertiary educated. While 87% of respondents recognized a sample prescription, 20% could not readily match the prescription to a labelled medicine box. Eighty‐two percentage of respondents interpreted ‘three times a day’ appropriately, but interpretation of a standard ancillary label was highly variable. Advanced age, less formal education, non‐English‐speaking background and male gender were independently related to lower performance in some variables.
Discussion This health literacy measure applied comprehension and numeracy skills required of adults receiving prescription medications. While the majority of consumers adequately performed these tasks, some behaviours and responses were of sufficient concern to propose additional verbal and written information interventions by pharmacy staff.
Conclusions This research provides insight into issues that may affect consumers’ appropriate use of medicines and self‐efficacy. Initiatives to improve public health literacy are warranted.
Current research on health literacy suggests that it is an under‐recognized problem in health care and that people with lower levels of health literacy lack the skills and knowledge to understand the appropriate way to use medicines, hence compromising their safe and effective use of medicines.
This study explored functional, interactive and critical health literacy, using questions that investigated comprehension and numeracy skills required of an adult consumer receiving a prescription medicine from a community pharmacy. The sample of 647 respondents exceeded the intended 400 respondents and facilitated statistical comparisons. Further multivariate and qualitative analyses will be reported elsewhere.
While the majority of participants were familiar with key aspects of prescriptions, the questions that required understanding of instruction and warning labels challenged some. Our data revealed that nearly one in five participants miscomprehended the dose spacing implied by ‘take ONE tablet THREE times a day,’ an error that could lead to sub‐therapeutic effects, overdose or other undesirable effects. Further, while nearly all participants were able to identify a warning label on a medicine box, only 4% correctly and fully explained the concepts within the label; others commonly truncated and interpreted the key message as ‘avoid alcohol’ or ‘do not drive’, losing the subtleties of the message. While the interpretations commonly erred on the side of conservatism and few could be considered dangerous, it was of some concern that a number of participants mentioned that they ignore labels where the print size is too small, which could have critical consequences depending on the medicine. Conversely, others stated that they would be cautious if they saw a warning label even it was unreadable. This latter reticence may be insufficient to avoid harm, but in some cases, the medicine might not be taken at all. In general though, ignorance or misunderstanding of this label, which advises of possible drowsiness and enhanced effects of alcohol and warns about driving or operating machinery if affected, has the potential to increase an individual’s risk of injury and/or excessive sedation (Table 1).
One indicator of functional literacy required participants to calculate the number of days’ worth of tablets remaining, given a card containing nine tablets; this was accomplished by 93% of the consumers. Our findings differ from those of Adams et al., 6 in which 21% of their sample were deemed highly likely to have ‘inadequate functional health literacy’ based on a series of six questions in a large‐scale household survey. While the questions in these studies cannot be directly compared, it could be that our approach of pharmacy clients in pharmacies overestimates the functional health literacy of consumers at large.
Previous studies have found that poorer health literacy is more common as age (>65 years) increases. 6 , 10 The process of ageing is associated with decline in biological and physiological functioning, which can lead to multiple medical conditions and reduced mental processing skills, 10 with potentially more confusion as a result of managing more medicines. These issues, and additional factors such as lower levels of formal education in the older generation, which significantly correlated with advancing age in our study, could contribute to poor health literacy in older health consumers. 10 Further, an increasingly complex health system could be a reason why earlier learning experiences are not useful as consumers’ age. A counter‐argument, not supported by our data, is that greater exposure to prescription medicine use in the elderly may enhance their familiarity and vigilance with medicines. In our study, 71% of customers aged >65 years were able to correctly match the sample prescription to the labelled box, compared to 89% in the 26–35 years age group. The responses from the elderly population were also more delayed, and vision problems led to some difficulties in reading the instruction and identifying and reading warning labels. These findings are similar to those from previous studies. 10 , 16 A common reported reason for participants not attempting to read the warning label was not having spectacles on their person. Research has identified that ‘making excuses’ is a coping mechanism for patients who have trouble reading medical forms and instructions. 17 The association of greater formal education and health literacy is worthy of further exploration. While at face value, this finding is logical, it is interesting that there remain a number of tertiary‐educated respondents who did not manage the tasks; this could be related to the tasks requiring interpretation and application of given information.
English was the first language for 89% of our respondents. Lack of English proficiency was associated with delayed and/or incorrect responses, lower likelihood of familiarity with the appearance of a prescription (65% vs. 89%) and greater difficulty in matching the prescription to the correctly labelled box, reading instructions and in recognizing a warning label. These data suggest that, however, difficult, pharmacists need to undertake medicine‐related counselling with non‐native‐English speakers to enhance their understanding of medicines information and appropriate usage. This, of course, assumes that the language deficiencies lie with the consumer, rather than the health professional; the latter is a topic of some concern and is being addressed in local initiatives. 18
Most participants readily offered suggestions to improve their understanding of medicines, predominantly relating to greater provision of verbal and written information, with a repeated message indicating the need for personalized counselling on indications for medicines, side effects and drug interactions, especially for initial therapy. These suggestions included larger font and simple wording on labels accompanied by clear explanations. In relation to generic substitution of medication, consumers expressed the need for tailored information. These suggestions may contribute toward improved adherence to a prescribed regimen. As such, it is recommended that pharmacists discuss relevant information and determine the consumers’ comprehension of this information.
Such communication is considered a core competency for pharmacists in Australia, 19 but data on the application of this competency are not readily available. Internationally, it is recognized that insufficient instructions are given to medicine consumers by general practitioners and pharmacists and that written information is a valuable reinforcement for verbally communicated instructions. 7
In conclusion, this study has provided insight into how community pharmacy consumers apply given information about medicines. Overall, the majority of participants comprehended the given information and displayed levels of health literacy that may result in safe and effective use of prescription medications. A key area of concern was consumers’ inability to readily locate a warning label on a sample medicine box, independently associated with advanced age, less formal education and non‐English‐speaking background. Further, incorrect matching of a sample prescription to a labeled box was associated with these three demographic variables, as well as male gender. These issues may result, respectively, in inappropriate use and mismanagement of medicines.
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This research article shows that community pharmacy plays a role in pharmaceutical literacy. The results of these findings were interesting, because it shows that the general public can misenterpret information directly on the medication they are taking, and how there can be some skimming involved in warning lables of pharmaceuticals.