Connecting pharmacy and literacy: The North Carolina medication information literacy project

American Journal of Pharmaceutical Education, Fall 2000 by Kirt, Julienne K, Krick, stacie, Futrell, Debra, Devora, Teresa, Et al

The purpose of this study was to involve pharmacy students in a project designed to evaluate the comprehension of consumer-directed, over the counter (OTC) medication information. This project was conducted statewide in North Carolina and was coordinated through an alliance of the University of North Caroline at Chapel Hill School of Pharmacy and the North Carolina Area Health Education Centers (AHEC) Program. Two other goals of this project were to expose pharmacy students to research and provide collaborative experience for AHEC-based faculty. The project was implemented over a three-month period during the fall of 1998 and included completion of patient comprehension surveys. Each study participant read an example of OTC patient instructions. Afterwards, students asked questions directly related to the OTC information. Surveys of 878 participants were completed. A comprehension score was calculated based on eleven questions obtained from the participant response form. Comprehension scores ranged between 6.7 and 8.4 using a scale that was based on the eleven questions worth one point each. Students were also asked to provide feedback by survey regarding how participant selection was conducted and a debriefing session allowed for discussion about project experience and improvement. This study indicates that OTC medication instructions are difficult to interpret for many consumers, that student participation in a community research project is a useful learning experience, and that geographically dispersed faculty can conduct collaborative research.

INTRODUCTION

Health care systems today require that patients be able to read and understand medication information. Inadequate literacy skills can be a barrier to good health care. In general, individuals with the lowest literacy have poorer health, higher expenses for health care, more outpatient visits, and a greater likelihood of hospitalization than those with better-developed reading skills(1). The high rate of illiteracy in the United States was illustrated by the 1992 National Adult Literacy Survey (NALS), which examined reading skills of 26,000 adults(2). Extrapolating the NALS data, it is predicted in North Carolina that nearly 22 percent (1.1 million) of the state's residents demonstrate "level one functional literacy skills" (level one = lowest and level five = highest). These adults would likely have serious literacy difficulties and need significant instruction.

Functional health literacy is the ability to read and comprehend information on medication bottles, appointment slips, and other essential health-related materials required to function as a patient. A person's functional health literacy may be worse than their general literacy(3). The NALS did not specifically test health literacy. However, there have been a number of studies, which have addressed a patient's health literacy(4-6). Together, these studies found that many patients do not have adequate health literacy skills to function successfully in health care systems.

The marginally literate person can sound out a sentence, but may not be able to understand the meaning or be able to respond to written instructions. It has been reported that nearly 42 percent of hospitalized patients surveyed, were unable to comprehend directions for taking medicine on an empty stomach(4). It is estimated that the average reading level of the American public is at seventh- to eighth-grade level. According to research, consumers need to read at the ninthgrade level to accurately interpret information on over-thecounter (OTC) medication labels(7).

In 1995, OTC and diagnostic agents amounted to over 20 billion dollars in sales for the United States(8). The majority of OTC sales are to the elderly, especially for cough and cold products. Safe and effective use of these products is not only dependent on adherence to directions, but to the understanding of warnings and contraindications that accompany the OTC product. Currently, this information varies in content and format on OTC product labels. The information is often written with language that is at a greater reading level than the reading ability of the consumer. Additionally, the print size, layout and design, and lack of diagrams may reduce readability. The end result is potential consumer misuse of OTC medications leading to an adverse effect or treatment failure. Comprehension of medication information, including preoperative instructions, consent forms and advance directives has been studied in various populations(4,6). However, we found no studies regarding comprehension of OTC medication information.

North Carolina is divided into nine Area Health Education Centers (AHEC) regions and each AHEC provides clerkship training for approximately 12 pharmacy students per year. The main objective of this project was to assess patient comprehension of an OTC medication insert, while jointly involving faculty and students in a meaningful research project on a statewide level. Equally important goals were to give students experience in administering a literacy survey regarding medication information, while exposing them to a process of conducting community-based research. A project was designed and implemented through the University of North Carolina at Chapel Hill School of Pharmacy and the North Carolina AHEC Program.