1. World Heart Federation World Congress of Cardiology, 2012
Adherence to Medications: the importance of health literacy
Sophia, CHAN Siu Chee
Angela, LEUNG Yee Man
Michael, LAM Huen Sum
School of Nursing, the University of Hong Kong
19th April, 2012

2. Cardiac Disease and Medication Adherence
Heart failure and myocardial infarction require long- term use of medications to reduce morbidity and mortality. (Albert, 2008)
Potential Outcome of Non-adherence (Albert, 2008)

3. Cardiac Disease and Medication Adherence
Kravitz and colleagues (1993) shown that 66% of cardiovascular patients reported non- adherence to medications (N=1291).
Monane and colleagues (1994) shown only 10% of patients with heart failure adhere to therapy of taking medicine after 1 year (N=7247).

4. Cardiac Disease and Medication Adherence
Jackevicius et al (2008) shown that 24% of cardiovascular patients did not fill their cardiac medications by day 7 of discharge.
Among patients discharged with prescriptions for aspirin, statin, Ho and colleagues (2006) found that
1) 34% of patients stopped at least 1 medication
2) 12% stopped all 3 medications within 1 month of hospital discharge

5. Existing Interventions Good Enough?
A systematic Review (Dulmen, et.al., 2007) on 38 reviews of interventions to modify the medication adherence shown that:
Many interventions to improve patient adherence are unsuccessful;
Comprehensive and new theoretical foundations are inadequate;
Innovations in theory and practice are needed.
WE NEED TO EXPLORE ALTERNATIVE TACTICS!

6. What else affect Medication Adherence? Why Health Literacy?
Great demand of health information related to one’s own health after 2000 (Sihota & Lennard, 2004)
Flood of misleading, insufficient, non-scientific and uncontrollable quality of health information around living environment (Cline & Haynes, 2001)
Medication: Too many drugs! Averse effects? Confuse of drugs taken? Fears of communication with doctors and nurses! Forgot or not alert!
The skills to navigate, understand, interpret, analyze and communicate the right health information are therefore essential!
Health literacy (more sensitive and specific index of understanding medical instructions) > patient's education level (Weiss, 2003)

7. Health Literacy
“the ability to read, understand and act on health information” and “the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions” (USDHHS, 2005).
Emerged in the early 1990s (Cutilli, 2007)
Considered by the Office of Surgeon General of United States Department of Health and Human Services (USDHHS) as one of the four public health priorities (Galson, 2008).
Health illiteracy is a major ongoing problem of medication non-adherence of cardiac diseases (Oates & Paasche-Orlow, 2009)

8. Importance of Health Literacy on Medication Adherence of Cardiac Diseases
Low health litaracy has emerged as a potential predictor of non-adherence (Kalichman et. al., 1999)
Inadequate health literacy skills are related to impaired comprehension of medical care instructions, and as a consequence, reduced medication adherence (Pignone et. al., 2005)

9. Importance of Health Literacy on Medication Adherence of Cardiac Diseases
Chew et al. (2005) reported a trend toward reduced adherence with some preoperative medication instructions among patients with low health literacy skills.
Health numeracy (a part of health literacy) which defines as the degree to which individuals have the capacity to access, process, interpret, communicate, and act on numerical, biostatistical, and probabilistic health information needed to make effective health decisions, is important to the medication adherence (Golbeck et al 2005).

10. Existing Health Literacy Intervention on Medication Adherence
Very few(small systematic review in PubMed)
Started not until the end of first decade of millennium
Jefferey and colleagues (2010) and DeWalt and colleagues (2009) taken health literacy into their medication adherence-intervention of patients with cardiac diseases, however, either interventions are still under operation and no further updates were found.

11. Existing Health Literacy Intervention on Medication Adherence
Morrow and colleagues (2007)
Develop a patient-centre education program
Health literacy of patients were taken into consideration in the content of intervention
Patient centre instruction (intervention) were more preferred by the low health literate patients

12. Methods to increase health literacy of medication adherence
More training and teaching on medical terms and words
More training and teaching on numeracy concept of medication (e.g. times and frequency of taking medicine)
More patient centre educations are needed
More health interactions between patients and health practitioners
(Jefferey et al., 2010; DeWalt et al., 2009, Morrow
et al., 2007; Powell, Hill, & Clancy, 2007)

13. Methods to increase health literacy of medication adherence
More self confidence training on medicine takings are needed
Health beliefs and health decision making trainings are needed
More single behavior training is needed (e.g. medication only, diet only, exercise only), as patients cannot digest too many health information at single time, hence reduce the probability of designated health behaviors
(Jefferey et al., 2010; DeWalt et al., 2009, Morrow
et al., 2007; Powell, Hill, & Clancy, 2007)

14. Reference
Albert, N.M. (2008). Improving medication adherence in chronic cardiovascular disease. Critical Care Nurse. 28(5),
Chew, L.D., Bradley, K.A., Flum, D.R., Cornla, P.B., Koepsell, T.D. (2004). The impact of low health literacy on surgical practice. Am J Surg. 188(2)
Cline, R.J., & Haynes, K.M. (2001). Consumer health information seeking on the internet: The state of the art. Health Education Research, 16(6),
Cutilli, C. C. (2007). Health literacy in geriatric patients: An integrative review of the literature. Orthopaedic Nursing, 26(1),
DeWalt, D. A., Broucksou, K. A., Hawk, V., Baker, D. W., Schillinger, D., Ruo, B., Pignone, M. (2009). Comparison of a one-time educational intervention to a teach-to-goal educational intervention for self-management of heart failure: design of a randomized controlled trial. BMC Health Serv Res, 9, 99. doi: /
Dulmen, S.V., Sluijs, E., Dijk,L.V., Ridder, D., Heerdink, R., & Bensing, J. (2007). Patient adherence to medical treatment: a review of reviews. BMC Health Services Research, 7(55),
Galson, S. (2008). Minutes of the Board of Regents, Department of Health and Human Services National Institutes of Health, National Library of Medicine. Retrieved March 7, 2011, from
Ho, P.M., Spertus, J.A., Masoudi, F.A., Reid, K.J., Peterson, E.D., Magid, D.J., Krumholz, H.M., & Rumsfeld, J.S. (2006). Impact of medication therapy discontinuation on mortality after myocardial infraction. Arch Intern Med. 166,
Jackevicius, C.A., Li, P., & Tu, J.V. (2008). Prevalence, Predictors, and outcomes of primary nonadherence after acute myocardial infarction. Circulation. 117,

15. Reference
Kalichman, S.C., Ramachandran, B., & Catz, S. (1999). Adherence to combination antiretroviral therapies in HIV patients of low health literacy. J Gen Intern Med.14 (26) 7-73.
Kravitz, R.L., Hays, R.D., Sherbourne, C.D., Dimatteo, M.R., Rogers, W.H., Ordway, L., & Greenfield, S. (1993). Recall of recommendations and adherence to advice among patients with chronic medical conditions. Arch Intern Med. 153,
Monane, M., Bohn, R.L., Gurwhz, J.H., Glynn, R.J., & Avorn, J. (1994). Noncompliance with congestive heart failure therapy in the elderly. Arch Intern Med. 154,
Morrow, D. G., Weiner, M., Steinley, D., Young, J., & Murray, M. D. (2007). Patients' health literacy and experience with instructions: influence preferences for heart failure medication instructions. J Aging Health, 19(4), doi: /
Oates, D.J., & Paasche-Orlow, M.K. (2009). Health literacy: communication strategies to improve patients comprehension of cardiovascular health. Circulation, 119, 1049 –1051.
Pignone, M., DeWalt, D.A., Sheridan, S., Berkman, N., & Lohr, K.N. (2005). Interventions to improve health outcomes for patients with low literacy. A systematic review. J Gen Intern Med. 20(2)
Powell, C. K., Hill, E. G., & Clancy, D. E. (2007). The relationship between health literacy and diabetes knowledge and readiness to take health actions. Diabetes Educ, 33(1), doi: /
Schnipper, J. L., Roumie, C. L., Cawthon, C., Businger, A., Dalal, A. K., Mugalla, I., Kripalani, S. (2010). Rationale and design of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study. Circ Cardiovasc Qual Outcomes, 3(2), doi: /circoutcomes
Sihota, S., & Lennard., L. (2004). Health Literacy: Being able to make the most health. National Consumer Council.
United States Department of Health and Human Services (USDHHS), Office of Disease Prevention and Health Promotion. (2005). Healthy People Retrieve on August 2, 2007 from the web
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