Minimizing effects of low literacy on medication knowledge and compliance among the elderly

Academic and community hernia center websites in the United States fail to meet healthcare literacy standards of readability

BACKGROUND

Health literacy is considered the single best predictor of health status. Organizations including the American Medical Association (AMA) and the National Institutes of Health (NIH) have recommended that the readability of patient education materials not exceed the sixth-grade level. Our study focuses on the readability of self-designated hernia centers websites at both academic and community organizations across the United States to determine their ability to dispense patient information at an appropriate reading level.

METHODS

A search was conducted utilizing the Google search engine. The key words "Hernia Center" and "University Hernia Center" were used to identify links to surgical programs within the United States. The following readability tests were conducted via the program: Flesch-Kincaid Grade Level (FKGL), Gunning Fox Index (GFI), Coleman-Liau Index (CLI), Simple Measure of Gobbledygook (SMOG), and Flesch Reading Ease (FRE) score.

RESULTS

Of 96 websites, zero (0%) had fulfilled the recommended reading level in all four tests. The mean test scores for all non-academic centers (n = 50) were as follows: FKGL (11.14 ± 2.68), GFI (14.39 ± 3.07), CLI (9.29 ± 2.48) and SMOG (13.38 ± 2.03). The mean test scores [SK1] for all academic programs (n = 46) were as follows: FKGL (11.7 ± 2.66), GFI (15.01 ± 2.99), CLI (9.34 ± 1.91) and SMOG (13.71 ± 2.02). A one-sample t test was performed to compare the FKGL, GFI, CLI, and SMOG scores for each hernia center to a value of 6.9 (6.9 or less is considered an acceptable reading level) and a p value of 0.001 for all four tests were noted demonstrating statistical significance. The Academic and Community readability scores for both groups were compared to each other with a two-sample t test with a p value of > 0.05 for all four tests and there were no statistically significant differences.

CONCLUSION

Neither Academic nor Community hernia centers met the appropriate reading level of sixth-grade or less. Steps moving forward to improve patient comprehension and/or involving with their care should include appropriate reading level material, identification of a patient with a low literacy level with intervention or additional counseling when appropriate, and the addition of adjunct learning materials such as videos.

Factors influencing implementation of organizational health literacy: a realist review

PURPOSE

Healthcare systems are increasing in complexity, and to ensure people can use the system effectively, health organizations are increasingly interested in how to take an organizational health literacy (OHL) approach. OHL is a relatively new concept, and there is little evidence about how to successfully implement organizational health literacy interventions and frameworks. This study, a literature review, aims to explore the operationalization of OHL.

DESIGN/METHODOLOGY/APPROACH

A realist literature review, using a systems lens, was undertaken to examine how and why the operationalization of OHL contributed to changes in OHL and why interventions were more effective in some contexts than others. Initial scoping was followed by a formal literature search of Medline, CINAHL plus, Web of Science, Scopus, Embase and PsychINFO for original peer-reviewed publications evaluating OHL interventions until March, 2018.

FINDINGS

The search strategy yielded 174 publications; 17 of these were included in the review. Accreditation, policy drivers, executive leadership and cultures of quality improvement provided the context for effective OHL interventions. The dominant mechanisms influencing implementation of OHL interventions included staff knowledge of OHL, internal health literacy expertise, shared responsibility and a systematic approach to implementation.

RESEARCH LIMITATIONS/IMPLICATIONS

This study outlines what contexts and mechanisms are required to achieve particular outcomes in OHL operationalization. The context in which OHL implementation occurs is critical, as is the sequence of implementation.

ORIGINALITY/VALUE

Health services seeking to implement OHL need to understand these mechanisms so they can successfully operationalize OHL. This study advances the concept of OHL operationalization by contributing to the theory underpinning successful implementation of OHL.

What’s in a name? An overview of organisational health literacy terminology

Organisational health literacy (OHL) is a relatively new concept and its role in improving population health outcomes is gaining recognition. There are several terms being used in relation to OHL but there is no consensus about the definition of OHL nor agreement on a single approach to its application within health services. This contested space continues to create discussion and debate between health literacy researchers worldwide. Increasingly, health service accreditation standards are moving towards including OHL and so services need to clearly define their roles and responsibilities in this area. Inherent in this is the need to develop and validate quantifiable measures of OHL change. This is not to say it needs a ‘one-size-fits-all’ approach but rather that terminology needs to be fit for purpose. This paper reviews the literature on OHL, describing and contrasting OHL terminology to assist practitioners seeking OHL information and health services clarifying their roles and responsibilities in this area. What is known about the topic? Organisational health literacy (OHL) is a new and emerging field. Currently there is no agreed definition or approach to OHL. As a result there is a large number of terms being used to describe OHL and this can make it difficult for practitioners and health services to understand the meanings of the different terms and how they can be used when seeking OHL information and its application to health service policy. What does this paper add? This paper provides an overview of 19 different OHL terms currently in use and how they apply in a range of health service contexts. What are the implications for practitioners? This paper provides practitioners with an overview of OHL terms currently in use and how they can be used to seek information and evidence to inform practice or develop health service OHL policy. This will allow health services to ensure they can clearly define their roles and responsibilities in OHL for accreditation purposes by ensuring that terminology use is fit for purpose. Lastly, the paper provides an inventory of terminology to be used when searching for evidence-based practices in OHL. This ensures all relevant papers can be captured, leading to robust and thorough reviews of the evidence most relevant to the OHL area of focus.

Readability assessment of Internet-based patient education materials related to acoustic neuromas

OBJECTIVE

The objectives of this study were to assess the readability of Internet-based patient education materials related to acoustic neuromas (AN-IPEMs) by 4 widely validated readability indices, to evaluate scores against the existing sixth grade recommended reading level, and to compare the readability scores of patient education materials (PEMs) produced by professional organizations, clinical practices, hospitals, and miscellaneous sources.

MATERIALS AND METHODS

AN-IPEMs from 67 web sites (6 professional societies, 33 clinical practices, 19 hospitals, and 9 miscellaneous) were assessed using Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL), Simple Measure of Gobbledygook (SMOG), and Gunning Frequency of Gobbledygook (Gunning FOG). Scores were then evaluated against national recommendations by 1-tailed t tests and against each other using 1-way ANOVAs.

RESULTS

The average FKGL, SMOG, and Gunning FOG scores were all significantly higher than the recommended sixth grade reading level suggested by the USDHHS (p < 0.0001, single sample 1-tailed t test). Zero articles, by all indices, had a reading level equal to or below the sixth grade reading level. The FKGLs also varied between the various sources at a significant level (p = 0.01 one-way ANOVA independent samples). The average FKGLs of clinical practice and professional society AN-IPEMs were significantly higher than the average FKGLs of hospital AN-IPEMs (both p ≤ 0.05 one-tailed t-tests assuming unequal variances).

CONCLUSION

AN-IPEMs are written at a level significantly higher than that suggested by national recommendations. Current AN-IPEMs may need to be revised in order to enhance patient comprehension.

Impact of health literacy on outcomes and effectiveness of an educational intervention in patients with chronic diseases

OBJECTIVE

Study impact of health literacy on educational intervention for patients "Living with Coronary Artery Disease."

METHODS

187 patients were randomized to: VHS/DVD plus printed booklet; or booklet alone prior to scheduled visit. Main outcome measures included CAD knowledge assessment, clinical outcomes (weigh and blood pressure) and health behaviors (diet, exercise, and smoking); while functional health literacy was assessed as a possible predictor variable.

RESULTS

Knowledge scores and health behaviors improved following both interventions. Those receiving the booklet and video also had a significant improvement in exercise, and weight loss. There was a trend (p=0.07) towards greater improvement in test scores among those receiving the booklet plus video. Patients with lower health literacy benefited as much as higher literacy patients.

CONCLUSIONS

Incorporation of an educational program into clinical visits for patients with chronic disease improved disease-specific knowledge and prompted patients to become activated and involved in their care, improving health behaviors and outcomes. Lower health literacy was not a barrier to this beneficial effect.

PRACTICE IMPLICATIONS

Patients with lower health literacy may also benefit from educational, shared decision-making interventions.

Assessing readability of patient education materials: current role in orthopaedics

BACKGROUND

Health literacy is the single best predictor of an individual's health status. It is important to customize health-related education material to the individual patient's level of reading skills. Readability of a given text is the objective measurement of the reading skills one should possess to understand the written material.

QUESTIONS/PURPOSES

In this article, some of the commonly used readability assessment tools are discussed and guidelines to improve the comprehension of patient education handouts are provided. Where are we now? Several healthcare organizations have recommended the readability of patient education materials be no higher than sixth- to eighth-grade level. However, most of the patient education materials currently available on major orthopaedic Web sites are written at a reading level that may be too advanced for comprehension by a substantial proportion of the population. WHERE DO WE NEED TO GO?: There are several readily available and validated tools for assessing the readability of written materials. While use of audiovisual aids such as video clips, line drawings, models, and charts can enhance the comprehension of a health-related topic, standard readability tools cannot construe such enhancements. HOW DO WE GET THERE?: Given the variability in the capacity to comprehend health-related materials among individuals seeking orthopaedic care, stratifying the contents of patient education materials at different levels of complexity will likely improve health literacy and enhance patient-centered communication.

A low-literacy medication education tool for safety-net hospital patients

BACKGROUND

To improve medication adherence in cardiac patients, in partnership with a safety-net provider, this research team developed and evaluated a low-literacy medication education tool.

METHODS

Using principles of community-based participatory research, the team developed a prototype of a low-literacy hospital discharge medication education tool, customizable for each patient, featuring instruction-specific icons and pictures of pills. In 2007, a randomized controlled clinical trial was performed, testing the tool's effect on posthospitalization self-reported medication adherence and knowledge, 2 weeks postdischarge in English- and Spanish-speaking safety-net inpatients. To validate the self-report measure, 4 weeks postdischarge, investigators collected self-reports of the number of pills remaining for each medication in a subsample of participants. Nurses rated tool acceptability.

RESULTS

Among the 166/210 eligible participants (79%) completing the Week-2 interview, self-reported medication adherence was 70% (95% CI=62%, 79%) in intervention participants and 78% (95% CI=72%, 84%) in controls (p=0.13). Among the 85 participants (31%) completing the Week-4 interview, self-reported pill counts indicated high adherence (greater than 90%) and did not differ between study arms. Self-reported adherence was correlated with self-reported pill count in intervention participants (R=0.5, p=0.004) but not in controls (R=0.07, p=0.65). There were no differences by study arm in medication knowledge. The nurses rated the tool as highly acceptable.

CONCLUSIONS

Although the evaluation did not demonstrate the tool to have any effect on self-reported medication adherence, patients who received the schedule self-reported their medication adherence more accurately, perhaps indicating improved understanding of their medication regimen and awareness of non-adherence.

Complex interventions to improve the health of people with limited literacy: A systematic review

OBJECTIVE

To evaluate the published literature on the effects of complex (multi-faceted) interventions intended to improve the health-related outcomes of individuals with limited literacy or numeracy.

METHODS

We undertook a systematic review of randomized and quasi-randomized controlled trials with a narrative synthesis. The search strategy included searching eight databases from start date to 2007, reference checking and contacting expert informants. After the initial screen, two reviewers independently assessed eligibility, extracted data and evaluated study quality.

RESULTS

The searches yielded 2734 non-duplicate items, which were reduced to 15 trials. Two interventions were directed at health professionals, one intervention was literacy education, and 12 were health education/management interventions. The quality of the trials was mixed, 13/15 trials were conducted in North America, and all focused on literacy rather than numeracy. 13/15 trials reported at least one significant difference in primary outcome, all favoring the intervention group. Only 8/15 trials measured direct clinical outcomes. Knowledge and self-efficacy were the class of outcome most likely to improve.

CONCLUSION

A wide variety of complex interventions for adults with limited literacy are able to improve some health-related outcomes.

PRACTICE IMPLICATIONS

This review supports the wider introduction of interventions for people with limited literacy, particularly within an evaluation context.

Health literacy: an overlooked factor in understanding HIV health disparities

BACKGROUND

Limited health literacy may be a contributing factor to racial disparities in health care. This study examined the mediating effect of limited health literacy on the relationship between race and HIV-medication adherence.

METHODS

A total of 204 patients infected with HIV were recruited from two clinics in 2001. Structured in-person interviews were conducted to obtain information on patient demographics, medication adherence, and health literacy. Multivariate regression models were run in 2006 to examine the associations among race, literacy, and HIV-medication adherence after adjusting for relevant covariates.

RESULTS

In an adjusted analysis that excluded literacy, African Americans were 2.40 times more likely to be nonadherent to their HIV-medication regimen than whites (95% confidence interval [CI]=1.14-5.08). When literacy was included in the final model, the effect estimates of race diminished 25% to nonsignificance. Literacy remained a significant independent predictor of nonadherence (adjusted odds ratio [AOR]=2.12, 95% CI=1.93-2.32).

CONCLUSIONS

In this study, limited health literacy mediated the relationship between race and HIV-medication adherence. Investigators need to consider the potential utility of responding to literacy and communication barriers in health care as part of interventions to reduce racial disparities.

Development of an illustrated medication schedule as a low-literacy patient education tool

OBJECTIVE

Patients with low health literacy have difficulty understanding prescription drug labels and other medication instructions. This article describes the development, implementation, and preliminary evaluation of an illustrated medication schedule (a "pill card") that depicts a patient's daily medication regimen using pill images and icons.

METHODS

Participants in a randomized controlled trial who were assigned to receive the pill card intervention described their use of the card and its perceived effectiveness. Responses were analyzed by level of patient literacy and other characteristics.

RESULTS

Among the 209 respondents, 173 (83%) reported using the pill card when they initially received it, though use declined to 60% approximately 3 months later. Patients with inadequate or marginal literacy skills, less than high school education, or cognitive impairment were most likely to refer to the card on a regular basis initially and at 3 months (p<0.05). Most pill card users (92%) rated the tool as very easy to understand, and 94% found it helpful for remembering important medication information, such as the name, purpose, or time of administration.

CONCLUSION

Nearly all patients considered an illustrated medication schedule to be a useful and easily understood tool to assist with medication management. Patients with limited literacy skills, educational attainment, or cognitive function referred to the aid with greater frequency.

PRACTICE IMPLICATIONS

Picture-based instructions promote better understanding of prescription medications, particularly among patients with limited literacy skills or cognitive impairment, and should be used more widely in practice.

Health Literacy in Geriatric Patients

The concept of health literacy is a recent addition to healthcare literature, appearing in the early to mid 1990s. Health literacy refers to individuals' ability to understand their healthcare issues and effectively care for themselves in the healthcare system. Individuals' health literacy abilities vary greatly and can be viewed on a continuum ranging from adequate to marginal to inadequate. Repeated research has demonstrated that older individuals, the geriatric patient population, are at risk of inadequate or marginal health literacy. This risk impacts health outcomes and cost for caring for the older people in our society who are the consumers of a large quantity of healthcare services. The demographic data from the research show that multiple factors influence an individual's health literacy. Besides age, individuals with less education, lower income, "blue collar" jobs, and poor health status (mental and physical) can be at risk of marginal or inadequate health literacy. Providing care to low health literacy patients is complicated by commercially prepared healthcare materials and presentations that are often written well above the average national literacy level. Studies in this review examine various approaches to healthcare education and provide viable options for educating those with low health literacy. This review stresses the importance of healthcare professionals identifying older individuals with marginal or inadequate health literacy and being able to provide education in an effective manner to this segment of the population.

Improving knowledge and skills for use of medication by patients after stroke: evaluation of a nursing intervention

OBJECTIVE

The objective of this study was to determine if a tailored nursing intervention, as opposed to usual rehabilitation care, can improve knowledge and behavioral skills for correct use of medication use in aged stroke patients.

DESIGN

Stratified random sampling created two homogenous groups: 73 intervention patients, who were provided with the nursing intervention program along with usual rehabilitation care, and 82 controls, who underwent usual rehabilitation care alone. Participants were assessed within the first week of admission to the rehabilitation ward, 3 mos after stroke (at the end of the intervention), and 6 mos after stroke. An assessment instrument measuring correct knowledge and skills concerning medications was used.

RESULTS

After 3 and 6 mos, intervention subjects were significantly better than controls in knowledge of shape and dosage of their medications, in knowledge of side effects and correct response to side effects, and in adherence to their dietary regimen. However, for knowledge of color and daily schedule of medications, there were differences at 3 mos, but differences were diminished after 6 mos.

CONCLUSIONS

This nursing intervention, tailored to the specific needs of the aged stroke patient, increased the patients' knowledge and skills concerning medication therapy, but to a limited extent and for a limited time.

Medication adherence and persistence: a comprehensive review

Estimates of adherence to long-term medication regimens range from 17% to 80%, and nonadherence (or nonpersistence) can lead to increased morbidity, mortality, and healthcare costs. Multifaceted interventions that target specific barriers to adherence are most effective, because they address the problems and reinforce positive behaviors. Providers must assess their patients' understanding of the illness and its treatment, communicate the benefits of the treatment, assess their patients' readiness to carry out the treatment plan, and discuss any barriers or obstacles to adherence that patients may have. A positive, supporting, and trusting relationship between patient and provider improves adherence. Individual patient factors also affect adherence. For example, conditions that impair cognition have a negative impact on adherence. Other factors--such as the lack of a support network, limited English proficiency, inability to obtain and pay for medications, or severe adverse effects or the fear of such effects--are all barriers to adherence. There are multiple reasons for nonadherence or nonpersistence; the solution needs to be tailored to the individual patient's needs. To have an impact on adherence, healthcare providers must understand the barriers to adherence and the methods or tools needed to overcome them. This report describes the barriers to medication adherence and persistence and interventions that have been used to address them; it also identifies interventions and compliance aids that practitioners and organizations can implement.

Interventions to improve health outcomes for patients with low literacy. A systematic review

OBJECTIVE

To perform a systematic review of interventions designed to improve health outcomes for persons with low literacy skills.

DATA SOURCES

We searched MEDLINE, Cumulative Index to Nursing and Allied Health (CINAHL), Educational Resources Information Center (ERIC), Public Affairs Information Service (PAIS), Industrial and Labor Relations Review (ILLR), PsycInfo, and Ageline from 1980 to 2003.

STUDY SELECTION

We included controlled and uncontrolled trials that measured literacy and examined the effect of interventions for people with low literacy on health outcomes, including health knowledge, health behaviors, use of health care resources, intermediate markers of disease status, and measures of morbidity or mortality. Two abstractors reviewed each study for inclusion. Disagreements were resolved by consensus among the research team.

DATA EXTRACTION

One reviewer abstracted data from each article into an evidence table; the second reviewer checked each entry. Disagreements about information in evidence tables were resolved by team consensus. Both data extractors independently completed an 11-item quality scale for each article; scores were averaged to give a final measure of article quality.

DATA SYNTHESIS

We identified 20 articles examining interventions designed to improve health among people with low literacy. The most common outcome studied was health knowledge; fewer studies examined health behaviors, intermediate markers, or measures of disease prevalence or severity. The effectiveness of interventions appeared mixed. Limitations in research quality and heterogeneity in outcome measures make drawing firm conclusions about effective strategies difficult. Only 5 articles examined the interaction between literacy level and the effect of the intervention; they also found mixed results.

CONCLUSIONS

Several interventions have been developed to improve health for people with low literacy. Limitations in study design, interventions tested, and outcomes assessed make drawing conclusions about effectiveness difficult. Further research is required to understand better the types of interventions that are most effective and efficient for overcoming literacy-related barriers to good health.

Interventions to improve medication compliance in older patients living in the community: a systematic review of the literature

Noncompliance affects all age groups, but older patients have specific barriers against effective medication use and can be more vulnerable to the incorrect use of medication. Some age-related barriers are vision loss and cognitive impairment. In people aged 60 years or older, noncompliance with medication regimens varies from 26-59%. In this article we review randomised controlled trials (RCTs) on interventions aimed to improve compliance with medication regimens in older patients living in the community. It is known from other reviews that multifaceted interventions, a combination of interventions, are more often effective than single-focus interventions, probably because these address a wider range of barriers. Also, an individual approach with specifically tailored interventions is effective at improving compliance. In this review the following two hypotheses are evaluated: i) multifaceted interventions improve compliance more successfully than single interventions; and ii) interventions that are tailored to patients improve compliance more successfully than generalised interventions. A systematic literature search in four databases produced 14 suitable RCTs with 23 interventions that we categorised as single or multifaceted, and generalised or tailored. Differences in medication compliance between the intervention group and the control group were in less than half of the comparisons in favour of the intervention group. Telephone-linked reminder systems achieved the most striking effect, looking at differences between the intervention and control group, and deserve further attention. Overall, multifaceted interventions and tailored interventions seemed to result more often in differences in compliance rates in older adults in favour of the intervention group compared with a control group than single and generalised interventions.

Compliance with National Cholesterol Education Program dietary and lifestyle guidelines among older women with self-reported hypercholesterolemia. The Women's Health Initiative

PURPOSE

Dietary therapy remains the first line of treatment for patients with high blood cholesterol levels. Among free-living persons, compliance with National Cholesterol Education Program (NCEP) dietary recommendations is uncertain.

SUBJECTS AND METHODS

We performed a cross-sectional, baseline analysis of 91,627 postmenopausal women enrolled in the Women's Health Initiative Observational Study. Among women with self-reported hypercholesterolemia, we ascertained factors associated with compliance with National Cholesterol Education Program dietary recommendations, defined for the Step II diet as <or=30% of total calories from fat, <7% of calories from saturated fat, and daily dietary cholesterol <200 mg.

RESULTS

Of the 13,777 participants who reported having high cholesterol levels requiring drug therapy, only 20% reported total fat, saturated fat, and dietary cholesterol consumption consistent with Step II dietary goals. Factors associated with Step II dietary compliance included having a college degree (odds ratio [OR] = 1.26; 95% confidence interval [CI]: 1.14 to 1.40), a prior cardiovascular event (OR = 1.48; 95% CI: 1.28 to 1.70), and consumption of five or more daily servings of fruits or vegetables (OR = 3.0; 95% CI: 2.7 to 3.3). Being married, smoking, a sedentary lifestyle, and a higher body mass index were all associated with reduced compliance (all P <0.0001). In the subsample in which plasma lipid levels were measured, dietary compliance was associated with higher levels of low-density lipoprotein cholesterol (P = 0.02).

CONCLUSION

Since the inception of the NCEP in 1985, health care providers, public health programs, and patients have not successfully implemented the dietary recommendations.

Adherence in social context

Much has been written about adherence to interventions in older adults. What has not been discussed as extensively is how adherence is influenced and affected by the multiple interacting layers of the social context. Guided by an ecological or multilevel system model, this paper explores how social context may impact adherence. We conclude that when considering strategies to promote adherence to a particular regime, one must take into consideration the interplay between the social context and the adherence-related behavior. Control Clin Trials 2000;21:184S-187S

Health literacy and the risk of hospital admission

OBJECTIVE

To determine the association between patient literacy and hospitalization.

DESIGN

Prospective cohort study.

SETTING

Urban public hospital.

PATIENTS

A total of 979 emergency department patients who participated in the Literacy in Health Care study and had completed an intake interview and literacy testing with the Test of Functional Health Literacy in Adults were eligible for this study. Of these, 958 (97.8%) had an electronic medical record available for 1994 and 1995.

MEASUREMENTS AND MAIN RESULTS

Hospital admissions to Grady Memorial Hospital during 1994 and 1995 were determined by the hospital information system. We used multivariate logistic regression to determine the independent association between inadequate functional health literacy and hospital admission. Patients with inadequate literacy were twice as likely as patients with adequate literacy to be hospitalized during 1994 and 1995 (31. 5% vs 14.9%, p <.001). After adjusting for age, gender, race, self-reported health, socioeconomic status, and health insurance, patients with inadequate literacy were more likely to be hospitalized than patients with adequate literacy (adjusted odds ratio [OR] 1.69; 95% confidence interval [CI] 1.13, 2.53). The association between inadequate literacy and hospital admission was strongest among patients who had been hospitalized in the year before study entry (OR 3.15; 95% CI 1.45, 6.85).

CONCLUSIONS

In this study population, patients with inadequate functional health literacy had an increased risk of hospital admission.

Randomized trial of geragogy-based medication instruction in the emergency department

BACKGROUND

Medication adherence by older adults who are discharged from the emergency department (ED) is an essential attribute of effective treatment. Researchers have demonstrated that delivery of well-structured instructions increases the knowledge of discharge regimens and increases adherence among ED populations.

OBJECTIVES

This study compared the level of medication knowledge of elderly ED patients receiving instruction by one of two teaching methods: the usual preprinted discharge instructions with handwritten medication information and individualized computer-generated discharge instructions designed within a geragogy framework.

METHOD

The geragogy intervention included large-print, easily readable, specific information ordered within the elderly memory schema. This schema consists of purpose, administration, and emergency information in that order. The Knowledge of Medication Subtest by Horn and Swain (1977) was administered by telephone 48 to 72 hours after discharge. Sixty patients (38 women, 22 men) with a mean age of 76 years were randomly assigned to groups and completed the study at three rural ED sites.

RESULTS

Subjects in the geragogy-based intervention group demonstrated significantly more knowledge of medications than did subjects experiencing the usual discharge teaching method (t = 2.19, p = .016).

CONCLUSIONS

These findings suggest that a medication teaching intervention geared to the special needs of the elderly can be effective in increasing medication knowledge.

Literacy levels of ophthalmic patient education materials

Health care providers have become increasingly aware of poor patient understanding of their illnesses and their treatments. A major, increasingly recognized factor in poor understanding and compliance is the low literacy skills of 90 million Americans. This article reviews the literature on the relationship between patients' literacy skills and the literacy levels required to read educational health care materials, and applies a similar analysis to commonly used ophthalmic patient-educational materials. Understanding the relationships between patient literacy skills and health care utilization will be critical in improving the efficiency of the health care system.

Compliance with treatment regimens in chronic asymptomatic diseases

At least one third of hospital admissions for heart failure result from noncompliance with therapeutic regimens, both dietary and pharmacologic. In chronic diseases, noncompliance with both lifestyle modification and medication regimens is a major health problem. Patients frequently stop taking their medications because they consider them ineffective or because they experience unpleasant side effects. In asymptomatic conditions, patients may believe they do not need the medication and may not even fill their prescription. If they do obtain the medications, they may forget to take them regularly. Educational efforts and behavioral techniques can improve patient compliance in chronic, asymptomatic conditions, but one of the most effective strategies remains improved patient-physician communication.