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

Risk factors for medication-related short-term readmissions in adults - a scoping review

BACKGROUND

Hospital readmissions due to medication-related problems occur frequently, burdening patients and caregivers emotionally and straining health care systems economically. In times of limited health care resources, interventions to mitigate the risk of medication-related readmissions should be prioritized to patients most likely to benefit. Focusing on general internal medicine patients, this scoping review aims to identify risk factors associated with drug-related 30-day hospital readmissions.

METHODS

We began by searching the Medline, Embase, and CINAHL databases from their inception dates to May 17, 2022 for studies reporting risk factors for 30-day drug-related readmissions. We included all peer-reviewed studies, while excluding literature reviews, conference abstracts, proceeding papers, editorials, and expert opinions. We also conducted backward citation searches of the included articles. Within the final sample, we analyzed the types and frequencies of risk factors mentioned.

RESULTS

After deduplication of the initial search results, 1159 titles and abstracts were screened for full-text adjudication. We read 101 full articles, of which we included 37. Thirteen more were collected via backward citation searches, resulting in a final sample of 50 articles. We identified five risk factor categories: (1) patient characteristics, (2) medication groups, (3) medication therapy problems, (4) adverse drug reactions, and (5) readmission diagnoses. The most commonly mentioned risk factors were polypharmacy, prescribing problems-especially underprescribing and suboptimal drug selection-and adherence issues. Medication groups associated with the highest risk of 30-day readmissions (mostly following adverse drug reactions) were antithrombotic agents, insulin, opioid analgesics, and diuretics. Preventable medication-related readmissions most often reflected prescribing problems and/or adherence issues.

CONCLUSIONS

This study's findings will help care teams prioritize patients for interventions to reduce medication-related hospital readmissions, which should increase patient safety. Further research is needed to analyze surrogate social parameters for the most common drug-related factors and their predictive value regarding medication-related readmissions.

A call for action: Educating pharmacists and pharmacy students in behaviour change techniques

The increasing impact of chronic disease, including cancer and heart disease on mortality signifies a need for the upskilling of health professionals in health behaviour change. Solely providing education and information to patients is generally not sufficient to change behaviour, and for any change to be sustained. The nature of pharmaceutical practice allows pharmacists to have frequent contact with patients in the community. Historically, pharmacists have often effectively engaged with patients to assist with behaviour change initiatives related to smoking cessation, weight loss or medication adherence. Unfortunately, such initiatives do not work for everyone, and more tailored and varied interventions are urgently needed to reduce the effects of chronic disease. In addition, with greater inaccessibility to hospitals and GP's (e.g., appointment wait times), it is imperative that pharmacists are upskilled in providing opportunistic health behaviour change techniques and interventions. Pharmacists need to practice to their full scope consistently and confidently, including the use of behavioural interventions. The following commentary therefore describes and provides recommendations for the upskilling of pharmacists and pharmacy students in opportunistic behaviour change. We outline nine key evidence-based behaviour change techniques, the active-ingredients of a behaviour change intervention, that are relevant to common encounters in professional practice by pharmacists, such as improving adherence to medications/treatments and health promotion initiatives. These include social support (practical and emotional), problem solving, anticipated regret, habit formation, behaviour substitution, restructuring the environment, information about others' approval, pros and cons, and monitoring and providing feedback on behaviour. Recommendations are then provided for how this upskilling can be taught to pharmacists and pharmacy students, as well as how they can use these techniques in their everyday practice.

Examining Health Literacy in Taiwanese Smoking Cessation Populations: A Multidimensional Evaluation of Sociodemographic Factors and Domain-Specific Competencies

BACKGROUND

Cigarette smoking is a serious global health issue. Limited studies previously analyzed health literacy components in patients undergoing smoking cessation interventions. This study focuses on individuals enrolled in smoking cessation services and investigates the distribution of health literacy in three domains (health care, disease prevention, and health promotion) and four abilities (access, understand, appraise, and apply health information). The study also explores the correlation between background factors (age, BMI, etc.) and health literacy, as well as the differences in health literacy levels among different background variables (gender, etc.).

METHODS

228 individuals completed the health literacy questionnaire. Descriptive statistical analysis, Pearson Correlation, and a Chi-Squared Test were employed to investigate the various health literacy levels and background variables.

RESULTS

68% had excellent or sufficient health literacy. A total of 32% were considered problematic or to have inadequate health literacy. Of the three domains of health literacy, participants performed better in the healthcare domain. More than one-third were problematic in accessing and appraising information.

CONCLUSIONS

this paper, being the pilot study in providing an analysis of health literacy components in individuals undergoing smoking cessation, could serve as a useful reference for devising interventions for different population groups in trying to maximize successful cessation rates.

Association between social support and medication literacy in older adults with hypertension

Background

Reduced physical function and reduced social networks place older adults with hypertension at high risk for medication-related harm. Medication literacy is one of the preventable factors that affect the success of drug therapy for hypertension. However, little is known about the level of medication literacy and its influencing factors in older adults with hypertension.

Objective

The purpose of this study was to investigate the levels of social support and medication literacy, and the association between them in older Chinese adult patients with hypertension.

Methods

A total of 362 older adult patients with hypertension were investigated using a demographic characteristics questionnaire, the Chinese Medication Literacy Scale for Hypertensive Patients (C-MLSHP) and the Social Support Rating Scale (SSRS). Pearson correlation analysis, canonical correlation analysis (CCA) and hierarchical linear regression were used to analyse the relationship between social support and medication literacy.

Results

Our results showed that the mean scores for the C-MLSHP and the SSRS for older adult patients with hypertension were 23.89 (SD = 4.66) and 39.22 (SD = 5.53), respectively. The results of the Pearson correlation analysis suggested that the score for social support was positively correlated with the score for medication literacy (r = 0.431, P < 0.01). The results of CCA demonstrate that older adult patients with hypertension who had more subjective (r _s = 0.682) and objective support (r _s = 0.817) performed better in knowledge (r _s = 0.633), skills (r _s = 0.631) and behavior literacy (r _s = 0.715). Hierarchical linear regression indicated that two dimensions of subjective support (B = 0.252, P < 0.001) and objective support (B = 0.690, P < 0.001) in social support were found to be independent predictors of medication literacy (R² = 0.335, F = 19.745, P < 0.001).

Conclusion

Social support is positively associated with medication literacy in older Chinese adult patients with hypertension. The study highlights the importance of social support in promoting medication literacy among older adult patients with hypertension.

Novel pictograms to improve pharmacist understanding of the number needed to treat (NNT)

INTRODUCTION

Number needed to treat (NNT) is a clinically useful "yardstick" used to gauge the efficacy of therapeutic interventions. The objective of this project was to develop and pilot a series of pictograms and assess their impact on pharmacist understanding of the NNT.

METHODS

Three decision aids containing NNT pictograms were developed following a preliminary literature review and three focus groups with current Australian-registered pharmacists and pharmacist interns. Pharmacists then tested the pictograms in a research pilot in clinical encounters until (1) ≥ 3 sessions had occurred or (2) a two-week period had elapsed from commencement. Knowledge assessment was administered both pre- and post-pilot. Transcription and inductive thematic analysis were applied to focus group data. Descriptive statistics, Wilcoxon signed rank, and McNemar's tests were used to analyse the pilot data.

RESULTS

Six core themes regarding NNT decision aid development were identified with >80% consensus across three focus groups (N = 11). Comparison of the pre-post measures (n = 10) showed an increase in median scores after use of NNT decision aids, correlating to a moderate Cohen classified effect size (d = 0.54). Wilcoxon matched pairs test demonstrated a statistically insignificant influence of NNT pictograms on the knowledge assessment survey (P > .05).

CONCLUSIONS

While the NNT is not a new concept, its incorporation as part of pictograms for health practitioner enrichment is novel. This pilot study suggests that utilizing decision aids with NNT pictograms as counselling adjuncts appears promising in the realm of enhancing pharmacists' understanding of the NNT.

Sex differences in social support perceived by polymedicated older adults with multimorbidity. MULTIPAP study

The beneficial effects of social support on morbidity, mortality, and quality of life are well known. Using the baseline data of the MULTIPAP study (n = 593), an observational, descriptive, cross-sectional study was carried out that analyzed the sex differences in the social support perceived by polymedicated adults aged 65 to 74 years with multimorbidity. The main outcome variable was social support measured through the Duke-UNC-11 Functional Social Support (DUFSS) questionnaire in its two dimensions (confident support and affective support). For both sexes, the perception of functional social support was correlated with being married or partnered and having a higher health-related quality of life utility index. In women, it was correlated with a higher level of education, living alone, and treatment adherence, and in men with higher monthly income, prescribed drugs and fewer diagnosed diseases.

Social Support is Associated with Survival in Patients Diagnosed with Gastrointestinal Cancer

PURPOSE

The aim of this study was to examine the link between psychological, behavioral, and social factors and survival in patients diagnosed with gastrointestinal cancer.

METHODS

A cohort of gastrointestinal cancer patients were administered a battery of questionnaires that assessed trauma, depression, social support, sleep, diet, exercise, quality of life, tobacco and alcohol use, pain, and fatigue. Analyses included Pearson's correlations, analyses of variance, Kaplan Meier survival, and Cox regression analyses.

RESULTS

Of the 568 patients, the majority were male (57.9%) and Caucasian (91.9%), with a mean age of 61 (S.D. = 10.7). The level of perceived social support was comparable to patients with other medical conditions. Sociodemographic predictors of social support included the number of years of education (r = 0.109, p = 0.05), marital status (F(6,387) = 5.465, p ≤ 0.001), and whether the patients' income met the family's basic needs (F(1,377) = 25.531, p < 0.001). Univariate analyses revealed that older age (p < 0.001), male gender (p = 0.007), being black (p = 0.005), diagnosis of hepatocellular carcinoma (p = 0.046), higher body mass index (p = 0.022), larger tumor size (p = 0.032), initial treatment including chemotherapy rather than surgery (p < 0.001), and lower level of perceived social support (p = 0.037) were associated with poorer survival. Using multivariate Cox regression and adjusting for all factors found to be significant in univariate survival analyses, older age (p = 0.024) and lower perceived social support (HR = 0.441, 95% CI = 0.233, 0.833; p = 0.012) were the factors that remained significantly associated with poorer survival.

CONCLUSION

There are several biological and psychosocial factors that predict cancer mortality. Social support appears to be a robust factor affecting mortality in gastrointestinal cancer patients.

'If not for this support, I would have left the treatment!': Qualitative study exploring the role of social support on medication adherence among pulmonary tuberculosis patients in Western India

Social support has been identified as a significant factor in addressing treatment barriers and facilitating treatment adherence. Using a descriptive design, this qualitative study aims at sharing personal feelings and social support-related experiences among pulmonary tuberculosis (TB) patients in Western India. A semi-structured interview guide was designed, and thirty-seven in-depth interviews were conducted. Descriptive thematic analysis was employed for reporting the themes and the results. The participants highlighted diverse social support experiences like empathy, compassion, trust, neglect, tangible aid, strained relationships with in-laws, health provider's support, strength, and motivation which influences their treatment adherent behaviour. Contrasting differences of social support experiences among adherent and non-adherent TB patients were also reported. The study has important ramifications for developing patient-centric social support intervention strategies, TB policy, and practice. The study has shown, 'if not for this support', patients would have left the treatment, and it is mainly because this debilitating disease robs people of their physical, social, economic, psychological, and emotional well-being far beyond the period when treatment is being administered. However, we resonate that addressing social support is not the only way, and TB elimination overall will require an optimal mix of enhanced biomedical, social, economic, and policy interventions.

Best practices for conducting and writing mixed methods research in social pharmacy

Mixed method approaches are increasingly being used in social pharmacy research due to its potential to uncover insights that are not possible with separate quantitative and qualitative studies. Despite their increasing use, there are some limitations in these publications. Typically, specific mixed method designs are not chosen, quantitative and qualitative data are not systematically integrated, and the credibility or validity of the approach is not addressed. In this paper, we discuss mixed method designs and their applications in social pharmacy. Different integration techniques and legitimation types are detailed. We describe new methodological developments and provide examples from recent mixed method studies in social pharmacy. Finally, we also provide recommendations for planning, conducting, reporting, and evaluating mixed method studies. We suggest that researchers interested in conducting mixed method studies follow recommended guidelines and obtain training in mixed methods to ensure that rigorous mixed method studies are conducted in social and administrative pharmacy.

The Impact of Social Determinants of Health on Medication Adherence: a Systematic Review and Meta-analysis

BACKGROUND

Medication adherence (MA) is critical to successful chronic disease management. It is not clear how social determinants of health (SDH) impact MA. We conducted a systematic review and meta-analysis to summarize the evidence on the relationship between SDH and MA.

METHODS

We conducted a systematic review of the literature using a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) format. A literature search was performed using three databases: PubMed, Scopus, and Cochrane Clinical Trials Register in December of 2018. Included studies were completed in the USA, included adults aged 18 years and older, measured at least one social determinant of health, and medication adherence was the primary outcome measure. Data from included full texts were independently extracted using a standardized data extraction form. We then conducted a meta-analysis and pooled the odds ratios from the included studies for each social determinant as well as for all SDH factors collectively.

RESULTS

A total of 3137 unduplicated abstracts were identified from our database searches. A total of 173 were selected for full text review after evaluating the abstract. A total of 29 articles were included for this systematic review. Economic-related SDH factors and MA were mostly commonly examined. The meta-analysis revealed a significant relationship between food insecurity (aOR = 0.56; 95% CI 0.42-0.7), housing instability (aOR = 0.64; 95% CI 0.44-0.93), and social determinants overall (aOR = 0.75; 95% CI 0.65-0.88) and medication adherence.

DISCUSSION

Food insecurity and housing instability most consistently impacted medication adherence. Although included studies were heterogenous and varied widely in SDH and MA measurements, adverse social determinants overall were significantly associated with lower MA. The relationship between SDH and MA warrants more attention and research by health care providers and policymakers.

Factors influencing patient participation in medication counseling at the community pharmacy: A systematic review

BACKGROUND

Findings document that patient participation in pharmacy encounters is associated with favorable outcomes. However, there is a need to understand factors that may enhance or hinder patient engagement and pharmacist counseling behaviors during their medication discussions. This review aims to: (1) identify barriers and facilitators for patient engagement in pharmacy consultations, (2) explore the relationship between patient factors (such as demographics and communication behavior) and subsequent pharmacist counseling behavior.

METHODS

A systematic review of literature using PRISMA guidelines examined studies published in English addressing influences on patient participation and the relationship between patient factors and pharmacist counseling behavior. Four databases were used - PubMed, CINAHL, PsycINFO, and Scopus. Findings were framed thematically within the constructs of Street's Linguistic Model of Patient Participation in Care (LM).

FINDINGS

Fifty studies from 1983 to 2019, including 37 using self-reported data, were identified. Patient involvement in patient-pharmacist communication was influenced by enabling factors such as patient knowledge, communication skills, and pharmacy environment. Predisposing factors for participation ranged from patients' beliefs and past experiences to demographic characteristics such as gender and age. Pharmacists' participative behavior with patients was positively associated with patients' engagement and perceived patient cues in the conversation.

CONCLUSION

This systematic review identified predictors of patients' engagement in pharmacy encounters drawing on LM framework. Various predisposing factors, enabling factors, and pharmacist' responses impacted patients' willingness to actively participate in medication counseling at community pharmacies. Equally important, studies documented considerable impact by patients on pharmacists' counseling behavior. Pharmacy encounters should no longer be viewed as controlled simply by pharmacists' expertise and agendas. Patient characteristics and factors such as patient question-asking and expectations also appear to be associated with and influence patient-pharmacist interpersonal communication. Additional research needs to address the identified facilitators and barriers to enhance patient participation and pharmacist counseling behavior.

Health Literacy and Medication Adherence in COPD Patients: When Caregiver Presence Is Not Sufficient

Limited health literacy (HL) is associated with a lower medication adherence in patients with chronic obstructive pulmonary disease (COPD). In this study, we examined the potential mitigating role of caregiver support on the relationship between HL and adherence to COPD medications. We conducted a prospective observational study of adults with COPD and their caregivers. HL was assessed using the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and COPD medication adherence was evaluated with the Medication Adherence Rating Scale (MARS). We also collected caregiver HL data for a subset of participants. We tested whether having a caregiver impacted the relationship between HL and medication adherence using cross-sectional data collected between 2011 and 2015. Our sample included 388 COPD patients and 97 caregivers. COPD patients with low HL had a lower medication adherence (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.24-0.81) after adjusting for sociodemographic factors. Caregiver presence was not associated with increased patient medication adherence (OR: 1.28, 95% CI: 0.79-2.08). Among the subset of patients with caregivers, low patient HL remained associated with a lower medication adherence (OR: 0.28, 95% CI: 0.09-0.82) when adjusted for caregiver HL and sociodemographic factors. Low HL is associated with lower COPD medication adherence, and this effect is not mitigated by the presence of a caregiver. These findings suggest a need for effective strategies to manage high-risk COPD patients with low HL, even among those with adequate support from caregivers, and to design interventions for both patients and caregivers with low HL.

Using a pharmacist-community health worker collaboration to address medication adherence barriers

OBJECTIVE

Pharmacists are positioned to evaluate and educate patients regarding medication adherence; however, opportunities exist to leverage a collaborative approach in eliciting barriers encountered by patients, especially in minority groups. Community health workers (CHWs) are individuals from the communities who form relationships with patients and help increase their access to health care resources. This study aimed to evaluate the effectiveness of a collaboration between CHWs and pharmacists in identifying and addressing medication adherence barriers faced by hypertensive patients.

METHODS

After receiving training in medication therapy management support, CHWs from the South East American Indian Council collaborated with students and pharmacists from the Center for Quality Medication Management at the University of Florida to identify and address medication adherence barriers encountered by hypertensive patients who were mainly Native American or black. The CHWs documented information from the patient interviews during the initial and follow-up visits. The team collaborated to identify intervention opportunities on the basis of the adherence barriers identified. Follow-up visits were conducted to measure progress.

RESULTS

Thirty-three hypertensive patients with or without diabetes were included in the study. The pharmacists, in partnership with the CHWs, offered 149 interventions related to medication adherence barriers. The most commonly identified barriers included forgetfulness, adverse effects, and knowledge concerns. By the final visits, 75.6% of the barriers related to antihypertensive medications and 63.9% of the barriers related to antidiabetic medications were resolved. In addition, a paired t test indicated a significant difference in the mean blood pressure values (P = 0.006 for systolic and P = 0.008 for diastolic) recorded at the initial (mean = 136/85.7 mm Hg) and final (mean = 130.1/81.2 mm Hg) visits.

CONCLUSION

The findings of this pilot project support the collaboration between pharmacists and CHWs to help improve medication adherence and patient outcomes. Additional research is recommended to validate these study findings.

Socioeconomic and Demographic Statuses as Determinants of Adherence to Antiretroviral Treatment in HIV Infected Patients: A Systematic Review of the Literature

BACKGROUND

Socioeconomic and demographic statuses are associated with adherence to the treatment of patients with several chronic diseases. However, there is a controversy regarding their impact on adherence among HIV/AIDS patients. Thus, we performed a systematic review of the evidence regarding the association of socioeconomic and demographic statuses with adherence to antiretroviral therapy (ART) among HIV/AIDS patients.

METHODS

The PubMed database was used to search and identify studies concerning about socioeconomic and demographic statuses and HIV/AIDS patients. Data were collected on the association between adherence to ART and varies determinants factors of socioeconomic (income, education, and employment/occupation) and socio-demographic (sex and age).

FINDINGS

From 393 potentially-relevant articles initially identified, 35 original studies were reviewed in detail, which contained data that were helpful in evaluating the association between socioeconomic/ demographic statuses and adherence to ART among HIV patients. Two original research study has specifically focused on the possible association between socioeconomic status and adherence to ART. Income, level of education, and employment/occupational status were significantly and positively associated with the level of adherence in 7 studies (36.8%), 7 studies (28.0%), and 4 studies (23.5%) respectively out of 19, 25, and 17 studies reviewed. Sex (being male), and age (per year increasing) were significantly and positively associated with the level of adherence in 5 studies (14.3%), and 9 studies (25.7%) respectively out of 35 studies reviewed. However, the determinant of socioeconomic and demographic statuses was not found to be significantly associated with adherence in studies related to income 9(47.4%), education 17(68.0%), employment/ occupational 10(58.8%), sex 27(77.1%), and age 25(71.4%).

CONCLUSION

The majority of the reviewed studies reported that there is no association between socio- demographic and economic variables and adherence to therapy. Whereas, some studies show that age of HIV patients (per year increasing) and sex (being male) were positively associated with adherence to ART. Among socio-economic factors, the available evidence does not provide conclusive support for the existence of a clear association with adherence to ART among HIV patients. There seems to be a positive trend between socioeconomic factors and adherence to ART in some of the reviewed studies.

Social support, social context and nonadherence to treatment in young senior patients with multimorbidity and polypharmacy followed-up in primary care. MULTIPAP Study

OBJECTIVE

To estimate the prevalence of nonadherence to treatment and its relationship with social support and social context in patients with multimorbidity and polypharmacy followed-up in primary care.

METHODS

This was an observational, descriptive, cross-sectional, multicenter study with an analytical approach. A total of 593 patients between 65-74 years of age with multimorbidity (≥3 diseases) and polypharmacy (≥5 drugs) during the last three months and agreed to participate in the MULTIPAP Study. The main variable was adherence (Morisky-Green). The predictors were social support (structural support and functional support (DUFSS)); sociodemographic variables; indicators of urban objective vulnerability; health-related quality of life (EQ-5D-5L-VAS & QALY); and clinical variables. Descriptive, bivariate and multivariate analyses with logistic regression models and robust estimators were performed.

RESULTS

Four out of ten patients were nonadherent, 47% had not completed primary education, 28.7% had an income ≤1050 €/month, 35% reported four or more IUVs, and the average perceived health-related quality of life (HRQOL) EQ-5D-5L-VAS was 65.5. The items that measure functional support, with significantly different means between nonadherent and adherent patients were receiving love and affection (-0.23; 95%CI: -0.40;-0.06), help when ill (-0.25; 95%CI: -0.42;-0.08), useful advice (-0.20; 95%CI: -0.37;-0.02), social invitations (-0.22; 95%CI:-0.44;-0.01), and recognition (-0.29; 95%CI:-0.50;-0.08). Factors associated with nonadherence were belonging to the medium vs. low tertile of functional support (0.62; 95%CI: 0.42;0.94), reporting less than four IUVs (0.69; 95%CI: 0.46;1.02) and higher HRQOL perception (0.98; 95%CI: 0.98;0.99).

CONCLUSIONS

Among patients 65-74 years of age with multimorbidity and polypharmacy, lower functional support was related to nonadherence to treatment. The nonadherence decreased in those patients with higher functional support, lower urban vulnerability and higher perceived health status according to the visual analog scale of health-related quality of life.

Level of medication self-management capacity among patients on ambulatory care exiting hospital pharmacy at Muhimbili National Hospital, Tanzania: a descriptive cross-sectional study

Objectives

Medication management capacity of a patient on ambulatory care is direct related to adherence. To our knowledge data on medication management capacity for ambulatory care patients exiting outpatient pharmacy outlets in Tanzania are scarce. This study aimed to determine the level of medication management capacity among patients on ambulatory care exiting Muhimbili National Hospital outpatient pharmacy outlet.

Results

A total of 424 patients on ambulatory care participated in the study. Three hundred eighty-seven (91.3%) out of 424 interview questionnaires had complete data and qualified for data analysis. Majority (62.3%) out of 387 study participants had poor medication management capacity; 65.3% out of 387 patients were unable to correctly read the prescription and match the drugs they are carrying. More than half (57.4%) out of 387 participants were unable to correctly take the dose, 73.9% out of 387 were unable to correctly tell the dosing frequency and duration. Only 10.6% out 155 patients with prescription containing drugs with warning or precaution or contraindication or potential side effects were aware.

A retrospective analysis of patient care activities in a community pharmacy mental illness and addictions program

BACKGROUND

The Bloom Program, a community pharmacy-based mental health and addictions care program, was developed and implemented to optimize pharmacists' care of eligible patients. Characterizing pharmacists' activities in the Bloom Program can facilitate program quality improvement and contribute more broadly to the knowledge base regarding pharmacists' roles and contributions to patient care.

OBJECTIVES

To characterize the patient care activities of the pharmacists in the Bloom Program.

METHODS

A retrospective analysis of patient charts for participants enrolled in the program for three months or longer was conducted. Using all available documentation, pharmacists' activities were coded into eight non-mutually exclusive categories: navigation/resource support, urgent triage, medication management, collaboration/communication, education, social support, self-care, and other.

RESULTS

2055 activities from 1144 patient care encounters were identified for 126 participants (48 ± 16 years of age, 61% female, 5 regular medications). Medication management was coded most often per encounter (73%). Each of social support, collaboration/communication, and education were coded in 20-25% of encounters. Frequency of navigation/resources, self-care, and urgent triage were 16.6%, 13.5%, and 2.8%, respectively. Non-medication management activities represented 59.4% of all pharmacist patient care services.

CONCLUSIONS

Medication management activities were coded in over 70% of patient encounters for pharmacists delivering a community pharmacy-based mental illness and addictions program. However, this accounted for 40.6% of activities with an average of 1.8 activities per encounter. Other activities were identified frequently (e.g., education, collaboration, social support, navigation and resource support) and help to characterize the nature of pharmacist-patient encounters and facilitates a better understanding of the role of the pharmacist in mental illness and addictions patient care.

Mediating effect of social support on the associations between health literacy, productive aging, and self-rated health among elderly Chinese adults in a newly urbanized community

With the growing urbanization of China, which has changed older adults' living conditions, lifestyle, and the source of support, coupled with rapid population aging, the health status of the elderly should be paid attention to. In addition to objective indicators such as the decline of function, specific factors, such as social support, health literacy, and productive aging, also have an impact on the health outcomes of the elderly. However, the interrelationships among these factors and their potential mechanisms in the context of urbanization remain unclear. Thus, this study was the first to explore the interrelationships among social support, health literacy, productive aging, and self-rated health in older adults living in a newly urbanized community in China.We aimed to investigate the mediating effect of social support on the associations between health literacy, productive aging, and self-rated health among elderly Chinese adults in a newly urbanized community to provide reference data for future health interventions for the elderly.This cross-sectional study was conducted between June and August 2013. Questionnaires on social support, health literacy, productive aging, and self-rated health were administered to 992 elderly residents. Structural equation models were used to examine the relationships among these 4 variables. Statistical analyses were performed using IBM SPSS Statistics 21.0 and Mplus 7.0.The mean scores for social support, health literacy, productive aging, and self-rated health were 34.5 ± 5.8, 13.6 ± 4.4, 11.3 ± 3.0, and 3.4 ± 0.7, respectively. Social support was directly related to self-rated health (β=0.119, 95% confidence interval [CI]: 0.041-0.198), while productive aging and health literacy had indirect associations with self-rated health via social support (β=0.071, 95% CI: 0.054-0.216; β=0.049, 95% CI: 0.066-0.183). Both productive aging (β=0.214, 95% CI: 0.047-0.381) and health literacy had direct associations with social support (β=0.327, 95% CI: 0.175-0.479), while health literacy had a direct association with productive aging (β=0.676, 95% CI: 0.604-0.748). Productive aging mediated the relationship between health literacy and social support.Overall, improving health outcomes among older adults requires enhancement of social support, along with consideration of productive aging and health literacy.

Depression, Social Support, and Adherence to Antiretroviral Therapy Among People Living With HIV in Guangxi, China: A Longitudinal Study

Depression can result in poor adherence to antiretroviral therapy (ART) among people living with HIV (PLHIV), and social support can help mitigate the negative relationship. However, little is known about how depression and social support synergistically influence ART adherence over time. The current study aims to explore longitudinal associations between them and examine which sources of social support can play a mediating role between depression and ART adherence over time. A randomized controlled clinical trial was conducted between 2013 and 2016 in Guangxi, China. The study sample was composed of 319 PLHIV who were randomized into control condition and provided data at baseline and at least one of the six follow-ups. The results revealed negative associations of depression with ART adherence over time, and a mediating effect of perceived support from spouse/partner or children. Interventions to promote ART adherence should focus on strengthening PLHIV's relationships with their spouse/partner and children, promoting collaborative provider-patient relationships, and enhancing peer support among PLHIV.

Exploring the customer orientation of Spanish pharmacy websites

Purpose

The strong regulation of the Spanish pharmaceutical sector encourages pharmacies to modify their business model, giving the customer a more relevant role by integrating 2.0 tools. However, the study of the implementation of these tools is still quite limited, especially in terms of a customer-oriented web page design. This paper aims to analyze the online presence of Spanish community pharmacies by studying the profile of their web pages to classify them by their degree of customer orientation.

Design/methodology/approach

In total, 710 community pharmacies were analyzed, of which 160 had Web pages. Using items drawn from the literature, content analysis was performed to evaluate the presence of these items on the web pages. Then, after analyzing the scores on the items, a cluster analysis was conducted to classify the pharmacies according to the degree of development of their online customer orientation strategy.

Findings

The number of pharmacies with a web page is quite low. The development of these websites is limited, and they have a more informational than relational role. The statistical analysis allows to classify the pharmacies in four groups according to their level of development

Practical implications

Pharmacists should make incremental use of their websites to facilitate real two-way communication with customers and other stakeholders to maintain a relationship with them by having incorporated the Web 2.0 and social media (SM) platforms.

Originality/value

This study analyses, from a marketing perspective, the degree of Web 2.0 adoption and the characteristics of the websites, in terms of aiding communication and interaction with customers in the Spanish pharmaceutical sector.

Association of functional and structural social support with medication adherence among individuals treated for coronary heart disease risk factors: Findings from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study

Background

Functional social support has a stronger association with medical treatment adherence than structural social support in several populations and disease conditions. Using a contemporary U.S. population of adults treated with medications for coronary heart disease (CHD) risk factors, the association between social support and medication adherence was examined.

Methods

We included 17,113 black and white men and women with CHD or CHD risk factors aged ≥45 years recruited 2003–2007 from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Participants reported their perceived social support (structural social support: being partnered, number of close friends, number of close relatives, and number of other adults in household; functional social support: having a caregiver in case of sickness or disability; combination of structural and functional social support: number of close friends or relatives seen at least monthly). Medication adherence was assessed using a 4-item scale. Multi-variable adjusted Poisson regression models were used to calculate prevalence ratios (PR) for the association between social support and medication adherence.

Results

Prevalence of medication adherence was 68.9%. Participants who saw >10 close friends or relatives at least monthly had higher prevalence of medication adherence (PR = 1.06; 95% CI: 1.00, 1.11) than those who saw ≤3 per month. Having a caregiver in case of sickness or disability, being partnered, number of close friends, number of close relatives, and number of other adults in household were not associated with medication adherence after adjusting for covariates.

Conclusions

Seeing multiple friends and relatives was associated with better medication adherence among individuals with CHD risk factors. Increasing social support with combined structural and functional components may help support medication adherence.

Multivariate analysis of covariates of adherence among HIV-positive mothers with low viral suppression

Background

As part of efforts to improve the prevention of mother-to-child transmission in Northern Uganda, we explored reasons for poor viral suppression among 122 pregnant and lactating women who were in care, received viral load tests, but had not achieved viral suppression and had more than 1000 copies/mL. Understanding the patient factors associated with low viral suppression was of interest to the Ministry of Health to guide the development of tools and interventions to achieve viral suppression for pregnant and lactating women newly initiating on ART as well as those on ART with unsuppressed viral load.

Methods

A facility-based cross-sectional and mixed methods study design was used, with retrospective medical record review. We assessed 122 HIV-positive mothers with known low viral suppression across 31 health facilities in Northern Uganda. Adjusted odds ratios were used to determine the covariates of adherence among HIV positive mothers using logistic regression. A study among health care providers shed further light on predictors of low viral suppression and a history of low early retention. This study was part of a larger national evaluation of the performance of integrated care services for mothers.

Results

Adherence defined as taking antiretroviral medications correctly everyday was low at 67.2%. The covariates of low adherence are: taking other medications in addition to ART, missed appointments in the past 6 months, experienced violence in the past 6 months, and faces obstacles to treatment. Mothers who were experiencing each of these covariates were less likely to adhere to treatment. These covariates were triangulated with perspectives of health providers as covariates of low adherence and included: long distances to health facility, missed appointments, running out of pills, sharing antiretroviral drugs, violence, and social lifestyles such as multiple sexual partners coupled with non-disclosure to partners. Inadequate counseling, stigma, and lack of client identity are the frontline factors accounting for the early loss of mothers from care.

Conclusions

Adherence of 67% was low for reliable viral suppression and accounts for the low viral suppression among HIV-positive mothers studied, in absence of any other factors. This study provided insights into the covariates for low adherence to ART and low viral load suppression; these covariates included taking other medications in addition to ART, missed appointments in the past 6 months, feels like giving up, doesn’t have someone with whom to share private concerns, experienced violence in the past 6 months, and faces obstacles to treatment and confirmed by health providers. To improve adherence, we recommend use of a screening tool to identify mothers with any of these covariates so that more intensive adherence support can be provided to these mothers.

Association of Social Support and Medication Adherence in Chinese Patients with Type 2 Diabetes Mellitus

The prevalence of diabetes is steadily increasing in China. When diabetes is uncontrolled, it generates dire consequences for health and well-being. Numerous studies have shown that health outcomes were associated with social support and medication adherence. Previous study confirmed that social support was associated with medication adherence in patients with heart failure, HIV diseases, and first-episode psychosis. However, the relationship between social support and medication adherence in patients with type 2 diabetes mellitus (T2DM) is remains unclear. This study aims to examine whether social support is associated with medication adherence in patients with T2DM. This study was conducted in the First Affiliated Hospital of the General Hospital of the People’s Liberation Army (PLA). In Beijing, a systematic random sample of 412 patients with T2DM over 18 years was recruited at baseline, and demographic characteristics, clinical data and their assessment of social support were collected from medical records and self-reported questionnaires. 330 of these patients completed a self-report measure of medication adherence at the sixth month after baseline data collection. Regression analysis showed that social support presented a positive effect on medication adherence, additionally, support utilization and the subscale of social support exhibited a significantly strong influence on medication adherence in patients with T2DM. Although medication adherence was influenced by multiple factors, this finding confirmed that social support must be recognized as a core element in interventions aimed at improving in the management of patients with T2DM.

Text Messaging May Engage and Benefit Adults with Type 2 Diabetes Regardless of Health Literacy Status

Background:

Technology-delivered interventions have the potential to improve diabetes self-care and glycemic control among adults with type 2 diabetes (T2D). However, patients who do not engage with interventions may not reap benefits, and there is little evidence on how engagement with mobile health interventions varies by health literacy status.

Objective:

This study explored how patients with limited health literacy engaged with and experienced Rapid Education/Encouragement and Communications for Health (REACH), a text messaging intervention designed to support the self-care adherence of disadvantaged patients with T2D. We recruited adults with T2D from federally qualified health centers and used mixed methods to examine (1) associations between users' health literacy status and their prior mobile phone use and their engagement with REACH and (2) similarities and differences in users' self-reported benefits by health literacy status.

Methods:

Participants (N = 55) completed a survey, including measures of health literacy and prior mobile phone use. For 2 weeks, participants experienced REACH, which included daily text messages promoting self-care and asking about medication adherence, and weekly text messages providing medication adherence feedback. After 2 weeks, participants completed a semi-structured telephone interview about their experiences.

Key Results:

Participants with limited health literacy were less likely to have used cell phones to access the Internet (48% vs. 90%, p = .001) or email (36% vs. 87%, p < .001), but equally as likely to have used text messaging and to respond to REACH text messages (p = .12 and p = .40, respectively) compared to participants with adequate health literacy. Participants responded to 93% of text messages on average and reported benefits of the intervention, including reminders and accountability, convenience and accessibility, and information and motivation. Participants with limited health literacy described a unique benefit of receiving social support from the intervention.

Conclusions:

Text messaging interventions may engage and benefit patients with T2D, regardless of health literacy status. Text messaging may have the potential to reduce T2D health disparities related to limited health literacy. [Health Literacy Research and Practice. 2017;1(4):e192–e202.]

Plain Language Summary:

Limited health literacy is associated with less engagement with health information technology, but there is little evidence on how engagement with text messaging interventions varies by health literacy status. This intervention engaged and benefited adults with type 2 diabetes in safety-net clinics, regardless of health literacy status. Participants with limited health literacy described a unique intervention benefit of social support.

Assessment of health literacy among outpatient clinics attendees at Ain Shams University Hospitals, Egypt: a cross-sectional study

OBJECTIVES

The aim of conducting this study is to measure health literacy (HL) and to investigate the factors associated with inadequate HL in a sample of outpatient clinics attendees (i.e. patients and companions) at Ain Shams University (ASU) Hospitals.

STUDY DESIGN

It is a cross-sectional study.

METHODS

The study was conducted on 805 attendees of the outpatient clinics at El-Demerdash University Hospital of ASU Hospitals. The Arabic versions of the Swedish Functional Health Literacy Scale and the European Health Literacy Survey Questionnaire-short version-were used to assess HL. The level of HL and factors influencing it were analyzed using correlation and binary logistic regression tests.

RESULTS

It was found that 81% of the participants had limited comprehensive health literacy (CHL; 34.3% inadequate and 46.7% problematic), while only 18.9% had sufficient CHL. Regarding functional health literacy (FHL), it was found that 84% had limited FHL (50.6% inadequate and 33.4% problematic), while only 16.1% had sufficient FHL. Females were more likely to have inadequate FHL. On the other hand, males, individuals with low educational levels, and attendees identified as patients as well as participants with inadequate FHL were more likely to have inadequate CHL.

CONCLUSION

The majority of our study population has limited HL. Extensive research is warranted to explore the extent of the problem on multi-institutional and national levels and to investigate more explanatory factors.

Health Literacy in a Social Context: Review of Quantitative Evidence

Background

Conceptual literature has consistently noted that health literacy exists within a social context. This review examined how the intersection of social context and health literacy has been operationalized in quantitative, empirical research.

Methods

Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched seven databases, including PubMed and CINAHL (The Cumulative Index to Nursing and Allied Health Literature), using a range of potentially relevant keywords, and we hand-searched bibliographies. Inclusion criteria were quantitative studies of any design in which measurement of health literacy and measurement of social context intersected. We identified 1,052 unduplicated articles; 34 met inclusion criteria.

Key Results

We found three distinct perspectives on the intersection between health literacy and social context. Most common (n = 23) were studies measuring an association between individual health literacy and individual social capital, social support, or social engagement, particularly whether social support varied by health literacy and/or if this relationship mediated health outcomes. Another group of studies (n = 6) took the perspective that being health literate by definition included social context, including access to and/or use of social support as a domain in individual health literacy assessment. Five studies considered the social context of health literacy as an independent property measured beyond the individual level; two measured community-level health literacy and three measured health literacy capacity/concordance in caregiving dyads. The studies showed significant definitional and measurement complexity and overlap. In the most dramatic example, a similar question was used across various studies to measure (1) health literacy, (2) a social support domain in health literacy, (3) social support, and (4) a study outcome distinct from, but associated with, health literacy. Potential useful methods, such as social network analyses, were missing from the literature.

Discussion

Existing quantitative research on health literacy in a social context supports more attention to this topic. This review quantified evidence, revealed gaps, noted limitations, and identified important questions for future research. [Health Literacy Research and Practice . 2017;1(2):e41-e70.].

Plain Language Summary

This study systemically compiles existing quantitative empirical research (34 articles) focusing on the intersection of health literacy in the social context. We find considerable measurement complexity in the current body of work on this topic and identify three distinct perspectives that researchers have taken while considering this topic. This information will be useful for future development of this important research area.

Health Literacy and Associated Factors Among Hmong American Immigrants: Addressing the Health Disparities

Hmong Americans face a disproportionate health burden ranging from the high prevalence of diabetes to depressive disorders. Little research attention has been paid toward exploring contributing factors to this disparity. As such, the present study seeks to fill the gap in the literature by examining the health literacy levels in Hmong Americans and its associated factors. The present study employed Andersen's behavioral model of health service as the theoretical framework. A cross-sectional survey research design was used and information was gathered from 168 Hmong American immigrants. Participants were recruited using a purposive sampling strategy. A multiple regression analysis was conducted to identify the factors linked to health literacy. Approximately half of the participants had low health literacy and reported that they did not understand health information well. Health literacy levels were found to differ significantly based on the number of years participants have lived in the U.S., their social or religious group attendance, health status, and whether they had difficulties with activities of daily living. Our exploratory findings could be used prompt more research to help inform the development of interventions aiming to improve health literacy levels and address the health disparities in Hmong American Population.

Family member-based supervision of patients with hypertension: a cluster randomized trial in rural China

Empirical evidence has suggested that social support from family can help patients take their medicines correctly. This study aims to evaluate the role of a family member-based supervision package in the management of hypertension using a cluster randomized trial in rural China. We recruited patients with hypertension from four villages in Yangzhong and randomly allocated them to the control group (n=288) and the intervention group (n=266). A family member-based supervision package was applied to the intervention group, while the usual service was applied to the controls. Patients were followed for 12 months and completed face-to-face interviews at the end of 6 and 12 months. The primary outcomes were patients' medication adherence and frequency of blood pressure measurement. Secondary outcomes included changes in blood pressure, altered risk behaviours and occurrence of hypertension-related complications. To control for the effects of cluster randomization, multilevel mixed-effects regression models were used to compare group changes. We observed that the intervention improved patients' blood pressure measurement frequency (OR: 9.00, 95% CI: 4.52-17.91) and adherence to antihypertensive treatment (OR: 1.74, 95% CI: 0.91-3.32). Its effect on the blood pressure control rate was significant at the mid-term investigation (OR: 0.67, 95% CI: 0.40-0.93), but the long-term effect was not significant (OR: 0.89, 95% CI: 0.64-1.26). After 6 months of intervention, either systolic or diastolic blood pressure was significantly decreased in the intervention group. However, this difference was not significant at the final investigation. Findings from this study revealed that the family member-based supervised therapy may have positive effects on patients' adherence to blood monitoring and hypertensive medications.

The Clarification of Depression and Social Support's Contribution to the Prediction of Antiretroviral Medication Adherence and the Rate of CD4 in People with HIV

With the development of the antiretroviral therapy, the number of the people with HIV is increasing; therefore, identifying the factors affecting HIV is of great importance. This study aimed to investigate the relationship between the antiretroviral medication adherence and the rate of CD4 with depression and social support in the people with HIV. The research method was a descriptive study kind of correlation. The statistical population included all patients with HIV in Shiraz, of whom, 220 people who had referred to the Behavioral Diseases Consultation Center were selected using the available sampling method. Philips et al.'s Social Support Questionnaire, Beck's Depression Questionnaire II, and ACTG Medication Adherence Questionnaire were used as the research tools. Results were analyzed using the stepwise regression and stepwise hierarchical multiple regression. Regression analysis showed that social support and depression variables could predict totally 47% (P<0.001) of changes of medication adherence variable, and depression could predict only 2% (P<0.01) of rate variance of CD4.

Associations Between Neighborhood Social Capital, Health Literacy, and Self-Rated Health Among People With Chronic Illness

Health literacy skills are important for health and self-management for people with chronic illness. Neighborhood social capital can provide resources, such as access to information and informal social control over unhealthy behavior. The benefit of these resources, and the access people have to these resources, might depend on levels of health literacy. We investigated whether neighborhood social capital is differentially related to the health of people with chronic illness according to health literacy skills. This study focused on health literacy skills in 4 domains related to the ability to access and understand health information and to the ability to perform self-management. We found a significant positive interaction between social capital and health literacy skills for accessing and understanding health information. This suggests that health literacy enhances people's ability to gain access to and use neighborhood resources to benefit health. There was no interaction effect between social capital and health literacy skills in the other 2 domains. More research is needed to investigate how people with chronic illness can benefit from knowledge, support, and other social resources for health and self-management also whether they have limited health literacy skills.

“These patients look lost” – Community pharmacy staff’s identification and support of patients with limited health literacy

Objective

To date, routine use of health literacy assessment in clinical settings is limited. The objective of this study was to explore if community pharmacy staff can identify patients with limited health literacy, how they identify patients and how they support patients to improve medication use. In addition, perceived barriers in providing care for patients with limited health literacy were assessed.

Methods

Structured face-to-face interviews with pharmacy staff were performed in 27 community pharmacies. Questions concerned pharmacy staff’s experiences with limited health literacy during their work, e.g. recognition of patients, communication strategies and possible interventions for this patient group to improve medication use.

Key findings

Results from 74 interviews were included for analysis. Sixty-eight interviewees (92%) mentioned to identify patients with limited health literacy during their work, mostly based on intuition. Suggested strategies to improve medication use included tailored education and information, intensive support or use of aids such as a multidose drug dispensing system. Pharmacy staff indicated lack of time as a barrier to provide tailored pharmaceutical care.

Conclusions

Most participants mentioned to recognize patients with limited health literacy merely on intuition or based on certain patient characteristics. Thus, an unknown number of patients with limited health literacy might be missed. This underlines the need to create more awareness of health literacy among pharmacy professionals. Moreover, training of pharmacy staff and use of aids to identify limited health literacy may help to identify more patients who need additional counselling.

Health Literacy Is Associated With Health Behaviors and Social Factors Among Older Adults: Results from the LifeLines Cohort Study

This study assesses the associations between health literacy and various health behaviors and social factors among older adults, and whether social factors moderate the other associations. Data from 3,241 participants in the LifeLines Cohort Study were analyzed (mean baseline age = 68.9 years). Data on health literacy, health behaviors (physical activity, fruit and vegetable consumption, smoking, breakfast consumption, alcohol consumption, and body mass index (BMI), and social factors (loneliness, social support, social activities, social contacts, and living situation) were collected in three waves. Logistic regression analyses were used, adjusted for age and gender. Low health literacy was associated with insufficient physical activity, insufficient fruit and vegetable consumption, lack of regular breakfast consumption, obesity (odds ratios (ORs) > 1.31, p-values < .005) and low alcohol use (OR = 0.81, p = .013), but not with smoking. Low health literacy was also associated with greater loneliness, engaging in fewer social activities, and having fewer social contacts (ORs > 1.48, p-values < .005), but not with social support or living situation. Only the association between health literacy and smoking was moderated by social contacts, but this finding needs confirmation in future studies. In conclusion, low health literacy is negatively associated with health behaviors and social factors in older adults, but social factors seldom moderate the associations between health literacy and health behaviors.

Can social support work virtually? Evaluation of rheumatoid arthritis patients' experiences with an interactive online tool

BACKGROUND

There is strong empirical evidence that the support that chronic patients receive from their environment is fundamental for the way they cope with physical and psychological suffering. Nevertheless, in the case of rheumatoid arthritis (RA), providing the appropriate social support is still a challenge, and such support has often proven to be elusive and unreliable in helping patients to manage the disease.

OBJECTIVES

To explore whether and how social support for RA patients can be provided online, and to assess the conditions under which such support is effective. An online support tool was designed to provide patients with both tailored information and opportunities to interact online with health professionals and fellow sufferers. The general purpose was to identify where the support provided did - or did not - help patients, and to judge whether the determinants of success lay more within patients - their engagement and willingness to participate - or within the design of the website itself.

METHODS

The present study reports qualitative interviews with 19 users of the tool. A more specific purpose was to elaborate qualitatively on results from a quantitative survey of users, which indicated that any positive impact was confined to practical matters of pain management rather than extending to more fundamental psychological outcomes such as acceptance.

RESULTS AND CONCLUSIONS

Overall, online learning and interaction can do much to help patients with the everyday stresses of their disease; however, its potential for more durable positive impact depends on various individual characteristics such as personality traits, existing social networks, and the severity and longevity of the disease.

Health Literacy, Smoking, and Health Indicators in African American Adults

We examined cross-sectional associations of health literacy (HL) with smoking and other established health indicators among 1,467 African American adults. Data emanated from a longitudinal cohort study designed to investigate cancer risk factors among church-going African American adults. We conducted linear and logistic regression analyses to assess associations between HL and health indicators. HL was assessed using an established single-item screening question. Outcomes included indicators of poor physical health (cigarette smoking, self-rated general and physical health) and mental health (self-rated mental health, depressive symptoms, perceived stress). Nearly 19% of participants had low HL. Low HL was significantly associated with current smoking, poorer self-rated general and physical health, and higher perceived stress (ps < .05) even after we controlled for demographic variables (i.e., age, gender, relationship status) and indicators of socioeconomic status (i.e., education, income, insurance status). Low HL appears to be an independent risk factor for smoking and other indicators of poor physical and mental health in a large sample of African American adults. Future directions and clinical implications are discussed.

Stress, depression and medication nonadherence in diabetes: test of the exacerbating and buffering effects of family support

Stressors and depressive symptoms have been associated with medication nonadherence among adults with type 2 diabetes (T2DM). We tested whether these associations were exacerbated by obstructive family behaviors or buffered by supportive family behaviors in a sample of 192 adults with T2DM and low socioeconomic status using unadjusted and adjusted regression models. We found support for the exacerbating hypothesis. Stressors and nonadherence were only associated at higher levels of obstructive family behaviors (interaction AOR = 1.12, p = .002). Similarly, depressive symptoms and nonadherence were only associated at higher levels of obstructive family behaviors (interaction AOR = 3.31, p = .002). When participants reported few obstructive family behaviors, neither stressors nor depressive symptoms were associated with nonadherence. We did not find support for the buffering hypothesis; stressors and depressive symptoms were associated with nonadherence regardless of supportive family behaviors. Nonadherent patients experiencing stressors and/or major depressive symptoms may benefit from interventions that reduce obstructive family behaviors.

Lower health literacy predicts smoking relapse among racially/ethnically diverse smokers with low socioeconomic status

BACKGROUND

Nearly half of U.S. adults have difficulties with health literacy (HL), which is defined as the ability to adequately obtain, process, and understand basic health information. Lower HL is associated with negative health behaviors and poor health outcomes. Racial/ethnic minorities and those with low socioeconomic status (SES) are disproportionately affected by poor HL. They also have higher smoking prevalence and more difficulty quitting smoking. Thus, lower HL may be uniquely associated with poorer cessation outcomes in this population.

METHODS

This study investigated the association between HL and smoking cessation outcomes among 200, low-SES, racially/ethnically diverse smokers enrolled in smoking cessation treatment. Logistic regression analyses adjusted for demographics (i.e., age, gender, race/ethnicity, relationship status), SES-related characteristics (i.e., education, income), and nicotine dependence were conducted to investigate associations between HL and smoking relapse at the end of treatment (3 weeks post quit day).

RESULTS

Results indicated that smokers with lower HL (score of < 64.5 on the Rapid Estimate of Adult Literacy in Medicine [REALM]) were significantly more likely than those with higher HL (score of ≥ 64.5 on the REALM) to relapse by the end of treatment, even after controlling for established predictors of cessation including demographics, SES, and nicotine dependence (OR = 3.26; 95% CI = 1.14, 9.26).

CONCLUSIONS

Findings suggest that lower HL may serve as an independent risk factor for smoking relapse among low-SES, racially/ethnically diverse smokers enrolled in treatment. Future research is needed to investigate longitudinal relations between HL and cessation outcomes and potential mechanisms of this relationship.

Social support mediates the association of health literacy and depression among racially/ethnically diverse smokers with low socioeconomic status

Nearly half of U.S. adults have health literacy (HL) difficulties, and lack the ability to effectively obtain, process, and understand health information. Poor HL is associated with depression, yet mechanisms of this relation are unclear. This study examined whether social support mediated the relation between HL and depressive symptoms in 200 low-socioeconomic status (SES), racially/ethnically diverse smokers enrolled in cessation treatment. Mediation analyses were conducted using bootstrapping and controlling for SES and nicotine dependence. In simple mediation models, social support [Interpersonal Support Evaluation List (ISEL) total, subscales (Appraisal, Belonging, Tangible)] mediated the effect of HL on depression, such that lower HL was associated with lower perceived support, which predicted higher depressive symptoms (ps < .05). A multiple mediation model, with ISEL subscales entered simultaneously as mediators, was significant (p < .05) but only the Belonging subscale demonstrating independent significance (p < .05). Thus, social support may be a critical factor underlying the HL-depression relationship in low-SES, racially/ethnically diverse smokers.

Impact of health literacy on medication adherence: a systematic review and meta-analysis

OBJECTIVE

To systematically review the literature and estimate the effect size of the relationship between health literacy and medication adherence through meta-analysis.

DATA SOURCES

Databases searched included Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982-2013), International Pharmaceutical Abstracts (IPA; 1970-2013), MEDLINE OVID (1966-2013), PubMed (1966-2013), PsycInfo (1966-2013), and Web of Science (1966-2013).

STUDY SELECTION AND DATA EXTRACTION

Inclusion criteria were as follows: English language; published through May 1, 2013; medication adherence as the outcome variable; use of validated measures of health literacy and medication adherence; availability of a direct (not mediating) relationship between health literacy and medication adherence; and identifiable effect size and statistical significance of the relationship. Exclusion criteria were as follows: duplicated results, irrelevant results, conference abstracts, proceeding papers, books, dissertations, reviews, editorial letters, continuing education units, or book reviews. Data included author, publication year, disease area, sample size, sampling method, location, study design, effect size of the relationship between health literacy and medication adherence, and measures of health literacy and medication adherence.

DATA SYNTHESIS

There is a small statistically significant and positive association between health literacy and medication adherence. In the conservative results, the unweighted and weighted correlation coefficients were 0.081 and 0.056 with P values <0.001. In the less conservative results, the unweighted and weighted correlation coefficients were 0.088 and 0.072.

CONCLUSIONS

The relationship between health literacy and medication adherence is statistically significant but weak. It is plausible that health literacy has a mediator relationship with other adherence determinants. Future research should explore such relationships.

Exploring the perspectives of potential consumers and healthcare professionals on the readability of a package insert: a case study of an over-the-counter medicine

PURPOSE

To explore and compare the opinions of physicians, pharmacists and potential users on the readability of a package insert of an over-the-counter medicine.

METHODS

Exploratory study based on the administration of a semi-open questionnaire. This instrument was developed according to the readability guideline of the European Medicine Agency (EMA) and used to evaluate participants' accessibility to, and comprehensibility of, the package insert for diclofenac 12.5 mg tablets. Sixty-three participants were recruited from the Lisbon region and enrolled in three groups: physicians (Dg), pharmacists (Pg) and potential consumers (PCg), with a minimum of 20 participants each.

RESULTS

Almost all (85 %) of the 20 PCg participants were educated above the 9th grade, although the majority of them (95 %) referred to, at least, one package insert interpretation issue, mainly related to the comprehension of technical terms. Amongst other differences between the groups, the Pg participants (n = 22) obtained a significantly less favourable opinion regarding the layout of the titles. Furthermore, the Pg and Dg (n = 21) participants proposed technical enhancements, such as the use of a table to explain the posology, precautions in case of renal failure, or the recommendation to take the tablets with meals.

CONCLUSIONS

Differences in the way of using the diclofenac tablets are expected, considering the comprehension dissimilarities between health professionals and potential consumers. The package insert of diclofenac 12.5 mg could be enhanced for safer use. Regarding the readability assessment of this package insert, the method proposed in the EMA guidelines might not be as effective as expected. Future research is advisable.

Family members' obstructive behaviors appear to be more harmful among adults with type 2 diabetes and limited health literacy

Family members' diabetes-specific obstructive behaviors (e.g., nagging/arguing or getting in the way of patients' self-care) are associated with adults having worse glycemic control (HbA1C), with diabetes-specific supportive family behaviors protecting against this detrimental effect. Given the role of family members in helping patients with limited health literacy, patients' health literacy status may moderate these relations. The authors tested this hypothesis with 192 adults with type 2 diabetes. Twenty-six percent had limited health literacy, and limited health literacy was associated with more supportive family behaviors (p<.05), but not with obstructive family behaviors or with patients' HbA1C. Adjusted stratified analyses indicated obstructive family behaviors were more strongly associated with worse HbA1C among participants with limited health literacy and low supportive family behaviors than for participants with adequate health literacy and low supportive family behaviors (adjusted simple slopes β=0.70, p=.05 vs. β=0.36, p=.009). However, there was no association between obstructive family behaviors and HbA1C in the context of high supportive family behaviors, regardless of health literacy status. Involving family members in adults' self-care without teaching them to avoid obstructive behaviors may be particularly harmful for patients with limited health literacy. Future research should identify intervention content to reduce obstructive family behaviors and identify which supportive family behaviors may be protective.

Effects of Physician Communication and Family Hardiness on Patient Medication Regimen Beliefs and Adherence

This study aims to develop a model that describes how physician communication and family hardiness affect medication regimen beliefs and adherence for patients on regimens to control diabetes and hyperlipidemia (high cholesterol). Study participants (n=1356) completed self-report questionnaires on health beliefs. Pharmacy refill records from a health plan in the United States provided data on their medication adherence. Structural equation modeling was used to model variable relationships. A mediation analysis demonstrated that physician communication behaviors had a significant impact on the patients' behavioral intention to adhere to their regimen and medication adherence when they were mediated by the patient's medication taking health beliefs related to perceived benefit of the regimen, impact of side effects, and cost of regimen. Conversely, family hardiness had no effect on medication-taking behaviors. To improve patient medication-taking behaviors, physician communication behaviors should be targeted. The study suggests the physician's initial regimen discussion is important to both regimen initiation and long-term adherence, and should emphasize the regimen's benefits and how to avoid common side effects. Also, establishing a follow-up physician-patient relationship can enhance regimen adherence and reduce the likelihood that a patient will stop taking the medication due to cost concerns. The research supports the important role the physician plays in health behavior maintenance. Future research should study the effect physicians have on other recurring health behaviors.

The social network paradigm and applications in pharmacy

BACKGROUND

There have been calls for research to include contextual and macrolevel factors within explanatory models of human health. A network approach focuses on the influence of relationships to predict behavior.

OBJECTIVES

The first objective was to describe the social network paradigm based in sociology that uses network principles and methods to visualize, quantify, and predict outcomes using the structure and function of relationships. The second objective was to discuss applications of this approach in the context of health to guide future research in pharmacy.

METHODS

This was a descriptive overview of conceptual models, methods, measures, and analyses that are used in the social network paradigm.

RESULTS

The social network paradigm contains conceptual models that rely on relational and structural assumptions to make predictions related to human behavior. Although there is not 1 dominate theory of social networks, several models hold across applications and are commonly used by scholars. The methodology emphasized considerations of network boundaries, sampling strategies, and the type of data collected. Specific variables used in social network analysis were defined and dichotomized into constructs of centrality and cohesion. Network analysis was described in terms of available computational programs, data management, and statistical testing. Related research in health care was applied and ideas for pharmacy were proposed using a social network-based theoretical model.

CONCLUSIONS

There is growing momentum for health behaviorists to gain familiarity for studying the effect of social networks on behavior. Applications in pharmacy using social network models, methods, and analysis can be used as a stand-alone perspective or in conjunction with other theoretical perspectives in an effort to explain human health or organizational behavior in health care settings.

Medication adherence, social support, and event-free survival in patients with heart failure

OBJECTIVES

Medication adherence and perceived social support (PSS) are independent predictors of mortality in patients with heart failure (HF). However, the predictive power of the combination of medication adherence and PSS for hospitalization and death has not been investigated in patients with HF. The purpose of the study was to explore the combined influence of medication adherence and PSS for prediction of cardiac event-free survival in patients with HF.

METHOD

A total of 218 HF patients monitored medication adherence for 1-3 months and completed the Multidimensional Perceived Social Support Scale (MPSSS) at baseline. Medication adherence was measured using a valid and objective measure, the Medication Event Monitoring System (MEMS). Patients were followed for up to 3.5 years to collect data about cardiac event-free survival (i.e., cardiac emergency department visits, hospitalizations, and death). To test the association of the combination of medication adherence and PSS with outcomes, the interaction term of medication adherence and PSS was first entered in a Cox regression to predict outcomes. Second, patients were grouped using an evidence-based cutpoint of 88% for medication adherence from the MEMS data and a median score 71 of the MPSSS. Kaplan-Meier and Cox proportional hazards models were used to compare cardiac event-free survival among groups.

RESULT

Medication adherence and PSS were independent predictors of cardiac event-free survival (p = .006 and .021, respectively). Patients with medication nonadherence and lower PSS had a 3.5 times higher risk of cardiac events than those who were adherent and had higher PSS.

CONCLUSION

Medication adherence mediated the relationship between PSS and cardiac event-free survival in this sample. Moreover, medication adherence and social support independently, and in combination, predicted cardiac event-free survival in patients with HF. Interventions to improve clinical outcomes should address medication adherence and social support.

Systematic review of consistency between adherence to cardiovascular or diabetes medication and health literacy in older adults

OBJECTIVE

To review the relationship between health literacy and adherence to cardiovascular/diabetes medication.

DATA SOURCES

We searched EMBASE (1974-February 2012) and MEDLINE (1948-February 2012). Search terms included health literacy, numeracy, health education and related terms, health literacy measurement tools, and medication adherence.

STUDY SELECTION AND DATA EXTRACTION

English-language articles of all study designs were considered. Articles were included if they had a measurement of health literacy and medication adherence and if participants were older adults taking drugs for cardiovascular illness or diabetes mellitus.

DATA SYNTHESIS

A total of 1310 citations were reviewed, including 9 articles that reported on 7 research studies. Most studies were retrospective, and all were based in the US. Because there was considerable diversity in measurements, participant characteristics, and outcome measures, we conducted a narrative synthesis rather than a meta-analysis. In assessing study validity, we looked at participant selection, method of measuring health literacy and medication adherence, missing data or losses, and adjustment for confounders. Of the 7 included studies, only 1 found a demonstrable association between health literacy and refill adherence. One clinical trial failed to show significant improvements in medication adherence after an intervention to improve health literacy.

CONCLUSIONS

The current evidence does not show a definite association between health literacy and medication adherence in older adults with cardiovascular disease or diabetes mellitus. In the absence of a definite link, efforts to develop interventions to improve health literacy would not necessarily improve adherence to cardiovascular medications. There is an urgent need for robust studies outside of the US, with wider, generalized recruitment of participants.

The relationship between depressive symptoms and medication nonadherence in type 2 diabetes: the role of social support

OBJECTIVE

Medication adherence promotion interventions are needed that target modifiable behavioral factors contributing to the link between depressive symptoms and poor adherence to diabetes self-care behaviors. In an effort to identify what factors contribute to this link, we examined the role of social support as a mediator of the relationship between depressive symptoms and medication nonadherence.

METHOD

We recruited 139 subjects with type 2 diabetes. Using an indirect effect test with bias-corrected (BC) bootstrapping, we tested whether depressive symptoms had an indirect effect on medication nonadherence through a lack of social support.

RESULTS

More depressive symptoms were associated with medication nonadherence (total effect=.06, P<.001), more depressive symptoms were associated with less social support (direct effect of the predictor on the mediator=-.96, P=.02), and less social support was associated with medication nonadherence (direct effect of the mediator on the outcome=-.01, P<.01). While the relationship between more depressive symptoms and medication nonadherence persisted with social support in the predicted pathway, the degree of this relationship was partially explained by a relationship between more depressive symptoms and less social support (indirect effect=.01, 95% BC bootstrapped confidence interval of .0005 to .0325).

CONCLUSION

Providing social support to patients with diabetes who have symptoms of depression may ameliorate some of the deleterious effects of depressive symptoms on medication nonadherence, but social support alone is not enough.

Factors influencing adherence to antiretroviral treatment in Nepal: a mixed-methods study

Background

Antiretroviral therapy (ART) is a lifesaver for individual patients treated for Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). Maintaining optimal adherence to antiretroviral drugs is essential for HIV infection management. This study aimed to understand the factors influencing adherence amongst ART-prescribed patients and care providers in Nepal.

Methods

A cross-sectional mixed-methods study surveying 330 ART-prescribed patients and 34 in-depth interviews with three different types of stakeholders: patients, care providers, and key people at policy level. Adherence was assessed through survey self-reporting and during the interviews. A multivariate logistic regression model was used to identify factors associated with adherence, supplemented with a thematic analysis of the interview transcripts.

Results

A total of 282 (85.5%) respondents reported complete adherence, i.e. no missed doses in the four-weeks prior to interview. Major factors influencing adherence were: non-disclosure of HIV status (OR = 17.99, p =  0.014); alcohol use (OR = 12.89, p = <0.001), being female (OR = 6.91, p = 0.001), being illiterate (OR = 4.58, p = 0.015), side-effects (OR = 6.04, p = 0.025), ART started ≤24 months (OR = 3.18, p = 0.009), travel time to hospital >1 hour (OR = 2.84, p = 0.035). Similarly, lack of knowledge and negative perception towards ART medications also significantly affected non-adherence. Transport costs (for repeat prescription), followed by pills running out, not wanting others to notice, side-effects, and being busy were the most common reasons for non-adherence. The interviews also revealed religious or ritual obstacles, stigma and discrimination, ART-associated costs, transport problems, lack of support, and side-effects as contributing to non-adherence.

Conclusion

Improving adherence requires a supportive environment; accessible treatment; clear instructions about regimens; and regimens tailored to individual patients’ lifestyles. Healthcare workers should address some of the practical and cultural issues around ART medicine whilst policy-makers should develop appropriate social policy to promote adherence among ART-prescribed patients.

The roles of past behavior and health beliefs in predicting medication adherence to a statin regimen

PURPOSE

Current medication-adherence predictive tools are based on patient medication-taking beliefs, but studying past behavior may now be a more explanatory and accessible method. This study will evaluate if past medication-refill behavior for a statin regimen is more predictive of medication adherence than patient medication-taking health beliefs.

PATIENTS AND METHODS

This prospective longitudinal study was implemented in a national managed care plan in the United States. A group of 1433 statin patients were identified and followed for 6 months. Medication-taking health beliefs, collected from self-reported mail questionnaires, and past medication-refill behavior, using proportion of days covered (PDC), were collected prior to 6-month follow-up. Outcomes were measured using categorical PDC variable (of adherence, PDC ≥ 85%, versus nonadherence, PDC < 85%), with model fit estimated using receiver operator characteristic analysis.

RESULTS

The area under the receiver operator characteristic curve for past behavior (A(z) = 0.78) was significantly greater (P < 0.05) than for patient health beliefs (A(z) = 0.69), indicating that past prescription-refill behavior is a better predictor of medication adherence than prospective health beliefs. Among health beliefs, the factor most related to medication adherence was behavioral intent (odds ratio, 5.12; 95% confidence interval, 1.84 to 15.06). The factor most strongly related to behavioral intent was impact of regimen on daily routine (odds ratio, 3.3; 95% confidence interval, 1.41 to 7.74).

CONCLUSION

Electronic medical records and community health-information networks may make past prescription-refill rates more accessible and assist physicians with managing medication-regimen adherence. Health beliefs, however, may still play an important role in influencing medication-taking behaviors.

My first patient as a nurse practitioner: a man with low literacy

PURPOSE

The purpose of this case study is to demonstrate the use of the nursing process and the standardized nursing languages of NANDA-I, the Nursing Outcomes Classification (NOC), and the Nursing Interventions Classification (NIC) to assist a man with low literacy to self-manage his medication regimen.

DATA SOURCES

The data sources for this article are clinical nursing practice, research evidence related to helping people with low literacy, and the books that explain NANDA-I, NOC, and NIC.

DATA SYNTHESIS

This case study demonstrates nurses' clinical decision making in providing care for a person with low health literacy.

CONCLUSIONS

Low health literacy should be considered when nurses identify the nursing diagnosis of Ineffective Self-Health Management. After trust is established, a screening tool should be used to evaluate the person's literacy level. Active partnership of the nurse and the person supports interventions to assist the person implement the medication regimen.

IMPLICATIONS FOR NURSING

Inadequate evaluation of health literacy may result in mislabeling a person as "nonadherent" or "noncompliant" to a medication or treatment regimen. Low literacy is often an unrecognized barrier to effective self-health management.