In this study the ML of clients acquiring prescription and non-prescription medicines in community pharmacies was analyzed using MedlitRxSE questionnaire in order to know the medication literacy of users, with special emphasis on the chronically ill with the future purpose of designing new strategies that allow the pharmacist and health personnel to prevent and reduce the errors in taking medicines and thus avoid the undesirable effects of any misuse.
Pharmacists, as other health care providers, sometimes use terminology that their patients find difficult to understand. Moreover, in contrast to comprehensive (verbal) patient therapy, it is not unusual for health care providers, including pharmacists, to rely heavily on written patient education materials such as the leaflets that usually accompany medicines (20).
However, there are differences between what patients really understand and what health care providers, including pharmacists, expect or believe them to know. Patients with low reading ability have been found to be substantially less likely to understand and remember drug advice, and more likely to have trouble knowing exactly what most health professionals recommend (3, 19, 20).
The incorrect use of medication is a major problem, not only because it diminishes the effectiveness of medicines, but also because of the high frequency of problems associated with their misuse (25). In this study, MedLitRxSE proved to be an effective and easy-to-use tool to assess the literacy of patients, and thus play an important role in ensuring patient safety and adherence to the instructions on how to use medicines provided by community pharmacies. Knowledge and improvement of ML could help reduce non-adherence to treatments, enabling patients to participate mor fully in their medication therapy (26).
Our result showed that only 34% of community pharmacy clients can be considered to have an adequate level of ML, which is similar to the findings of Sauceda et al. (13) in a population of 181 English and Spanish speaking patients in health centers and in the general population. Our results also suggest that ML decreases as the age of clients increase, as mentioned by Lee YM et al. (27). Another study showed that patients with limited health literacy have a significantly low understanding of the instructions on the label of medicine containers, and therefore a higher risk of having problems related to the medication (28).
A predictive factor of adequate total, documental and numerical literacy was the educational level of participants. Moreover, in the case of numeracy, a younger age was also seen to be a predictive factor. The same factors associated with ML are also mentioned in the literature as predictors of health literacy (29, 30). In a study conducted by Osborn et al. (29) with 205 patients, health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine (REALM) and the Wide Range Achievement Test, 3rd Edition (WRAT-3). The authors found that both numeracy and health literacy improved as the level of studies and income increased. Okamoto et al. (31) measured numeracy-ML in 300 people aged between 20 and 69 years using Lipkus and Schwartz scales. The first scale identified 46.33% of participants as having a low level of literacy, while the Schwartz scale identified 39.67% of participants as having a low literacy level. Men who had had a university education had the highest scores, while as age increased, the score decreased. Income did not have any effect on the results obtained for numeracy. In another study, using the short test on functional health literacy (S-TOFHLA) in a study of patients from different pharmacies in the United States, Backes and Kuo (32) observed that patients in general did not have an adequate functional level of health literacy, often did not remember the name of their treatment compared with patients considered to have a correct functional level of health literacy. The same occurred with remembering the correct dose and the frequency with which the medicine should be taken.
In view of our results, the advantages offered by using MedLitRxSE tool to analyze ML rather other health literacy questionnaires is that it allows the needs of clients, more specifically in the pharmaceutical environment, to be quickly and efficiently detected, thus improving pharmaceutical care and management of medications by the patient.
The results pointed to a decrease in adequate medication literacy as the number of medications consumed by the patient increases. However, in a study carried out by Lyles et al. (33) no association was found between health literacy and medication adherence or between health literacy and polypharmacy. Bauer et al. (34) studied the relationship between health literacy and adherence to following treatment correctly in a large cohort of patients treated with antidepressants during a 4 year follow-up and observed that 72% of patients could be classified as having limited health literacy, these patients show little adherence to medications compared to patients without such limitations.
Our results show that the scenario with the most problems of interpretation on the part of clients was that related with identifying the part of the body to inject a medicine. To solve this problem, it would be interesting to add illustrations to help patients with low levels of literacy to improve their understanding of how medicines should be used. Indeed, a study showed that this type of illustration could reduce errors both in the dosage of the medicine and resolve doubts about the part of the body where medication should be applied, at the same time increasing the degree of satisfaction with the care received in the community pharmacy in patients with low ML showed (35, 36). However, another study carried out with that the use of illustrations did not reinforce the information received only in written form (37). However, the illustrations must be clear because it has also been shown that the illustrations themselves may be a source of errors that result in improper administration of the medication (38). One alternative to the use of written information and illustrations could be providing the information about medication in audio format. This has been used for treating patients with a low level of health literacy with statins, and was seen to increase knowledge about the medication and patient satisfaction compared with those who received the usual information materials (39).
In terms of numeracy-ML, 57% answered the 4 questions correctly, unlike in the study carried out by Osborn et al. (29), in which only 38.24% of participants were adjudged to have an adequate level of numeracy-ML. Participants in our study made mistakes most frequently in the question related with the medication dose required, which can lead to overdosing. It should be noted that users with medium level or higher education had a significantly higher level of total ML than users without formal education or those with only primary education. In a study conducted in 7278 community pharmacy patients throughout Spain, Romero-Sanchez et al. (40) observed that uneducated patients had a higher risk of not understanding the information on the medication than patients with primary, secondary or university level studies.
The more frequently patients read information leaflets, the higher their score for total, numeracy and document-ML. In this sense, some authors have suggested that the habit of frequent reading is a powerful tool for improving health literacy (41).
It should be noted that the MedlitRxSE questionnaire has not been used in a wide variety of situations. Although these cut-off points are due to expert criteria, a certain subjective charge cannot be denied as a limitation. To our knowledge, there are few instruments exclusively dedicated to measuring ML. Therefore, one of the problems with discussing the data is that it is difficult to compare our results with other studies specifically referring to ML, whether or not MedLitRxSE was used or other similar tools.
In addition, the survey used in our research to measure ML does not measure the communication skills of patients, which forms part of health literacy and is essential for interaction with health professionals, with the health care system and for understanding the warnings related to medication and health (42).
On the other hand, the original instrument was developed in the United States with a Spanish-speaking sample there. In our study, the instrument was used in a completely different context, being a limitation of our study. In the original developmental study, the instrument was validated showing that it was related to the Short Test of Functional Health Literacy in Adults (S-TOFHLA), a measure of health literacy with only a few questions that directly address medication management. Therefore, MedLitRxSE has been validated as a measure of general health literacy. It may have content validity due to the nature of the questions, however in our study we have taken into account that the measure of knowledge about drugs is only valid in the sense that it includes questions about medication management.