Medication adherence, understanding and knowledge: Health literacy

Medication adherence is multidimensional, leading to many different theoretical frameworks and models when studying the subject and how best to improve it. This blog series will help show the many ways pharmacists are trained to identify medication adherence issues and how they’re uniquely equipped to spend time with a patient to address these issues.

In the study “Matching Adherence Interventions to Patient Determinants Using the Theoretical Domains Framework” published late 2016 in Frontiers in Pharmacology, 16 articles were examined to extract 103 interventions and 42 determinants. After reading this and other studies, the RxLive team categorized the reasons for medication adherence into six major buckets — Cost, Side Effects, Skills, Understanding and Knowledge, Social and Behavioral factors, and Access to Care and Burden of Regimen.

In the RxLive technology platform, whenever a pharmacist identifies a potential medication adherence problem, they can click that reason in the drop-down to receive a suggestion about addressing that adherence issue. This adds to their own deep knowledge and experience as they address medication adherence issues with each patient.

Health literacy: Core to Understanding and Knowledge

Health literacy is a dominant factor in the understanding and knowledge bucket that negatively impacts medication adherence, especially when compounded with lack of illness or therapy knowledge and challenges managing across multiple providers.

Health literacy contributes to reduced medication adherence, and is described by The Institute of Medicine (IoM) as the ability of an individual to make appropriate health decisions according to the extent of their capacity to obtain, communicate, understand and use health information. Health literacy requires an assortment of skills — reading, listening, communication, comprehension, analytical and numeracy — to execute a medication regimen. According to the Centers for Disease Control and Prevention (CDC), some form of health literacy affects 9 out of 10 adults who struggle to understand complex or unfamiliar health information. The 2003 National Assessment of Adult Literacy (NAAL) Survey revealed that only 12% of U.S. adults have proficient health literacy.

Inadequate health literacy skills impede patients’ ability to build knowledge about their illness and therapy, and creates challenges managing multiple providers involved in their care. Lack of illness knowledge and therapy can result in nonadherence, especially when symptoms aren’t present, stemming from unawareness of disease progression or the consequences of deviating from the medication regimen as prescribed. The Archives of Internal Medicine (Arch Intern Med) reported there was a strong correlation between patients’ health literacy with knowledge of their illness. Also, a lack of understanding of a therapy can influence patients’ trust and use of a medication.

Causes of health literacy and its effect on medication adherence

Variations in health literacy stem from differences in education, English proficiency, socioeconomic status and situational circumstances. The NAAL survey identified lower health literacy in adults 65 years of age and older, those with less education, and those who are medically underserved or uninsured.

Despite a prevalence of low health literacy in certain patient populations or areas, health literacy is situational. Even those with proficient health literacy may not understand health information in certain circumstances, such as when they are sick, in pain or frightened. Or all of the above.

Health literacy is a barrier to realizing the health outcome intended from medication therapy. Annals of Internal Medicine published that those with low health literacy are less likely to understand medication labels and are more likely to take medications incorrectly. The U.S. Dept. of Education reveals that adults with the lowest health literacy, numeracy and literacy skills self-reported the worst health of those assessed in NAAL. Improving health literacy will have a positive effect on patient health outcomes and can potentially reduce annual healthcare expenses by over $25 billion.

How pharmacists can identify medication adherence due to health literacy

Identifying low health literacy allows pharmacists to employ strategies that enable patients to use medication the way it was intended. Low health literacy can affect anyone, so attempting to identify based on groups such as elderly or those on Medicaid or lacking insurance is not sufficient.

Pharmacists should observe patient red flags for signs of low health literacy:

  • Incompletely filled-out forms
  • Missing medication refills for chronic conditions
  • Medications are referred to by their shapes or colors
  • Avoidance of reading printed material when in front of a pharmacist for reasons such as forgetting glasses or that the materials will be read with a spouse or child
  • Mispronouncing words
  • Presence of numerous folded papers in pockets or purse, or requesting more materials
  • Lack of asking questions during the course of counseling

How pharmacists can improve medication adherence through health literacy

  1. Gain trust and create a supportive environment
    Be aware that those with low health literacy may feel uncomfortable revealing their lack of understanding. Inadequate health literacy is associated with shame, causing patients to avoid asking questions or requesting that information be repeated or explained in a different way. Initially ask a patient what they know about a topic to assess their understanding. Ask open-ended questions in a respectful and caring tone that begin with “how” and “what;” avoid yes/no questions. Immediately engage the patient once low health literacy is identified, creating a welcoming environment where the patient feels comfortable.
  2. Apply the EDGE tactic: Explain, Demonstrate, Guide, Enable
    • Explain the medication label and how to use the medication, device or therapy emphasizing 3 to 5 key points. Patients may recall or understand only 50% of a medical session. Refrain from using complex medical terms. Everyday Words for Public Health Communication from the CDC offers simpler word choices for medical terms.
    • Demonstrate how to take the medication, use a device, or follow a technique. Draw or show pictures and utilize audiovisual information as supplements to demonstration. MedlinePlus has audiovisual education on over 250 topics in 40 languages that can be suggested for patient reference.
    • Guide in a teach-back method, encouraging the patient to repeat or practice the technique during the counseling session to identify areas that need further instruction. Reinforce what they already know to instill confidence and motivation.
    • Confirm through the teach-back method, patient’s body language and communication that they understand and feel enabled to administer the therapy independently. Additionally, use an open-ended approach to address any final issues that could affect medication adherence such as “What questions do you have,” rather than “Do you have any questions?”
  3. Create a written materials repository
    Create written materials that can be referenced to overcome information not retained during counseling sessions, increase health literacy and knowledge of illness and therapy, and to assist in the management of multiple providers. Develop common written materials such as: administration techniques, how to use devices, pictorial medication schedules, pharmacy forms, plain-language drug information sheets, and organizational instructions to build patient health/medication files for continuity of care between multiple providers. Brochures and materials should be written in a simple, concise conversational style, available in different languages, and written at or below a sixth-grade level. The Flesch-Kincaid Readability Formula in Microsoft Word is a tool to calculate the readability of written materials. Ample white space should be left on the materials, fonts no smaller than 12 point, and illustrations and pictures included.
  4. Collaborate with other healthcare providers
    According to a study published in the Journal of American Pharmacists Association, physicians recognize that pharmacists have deeper and broader information on medication adherence information and are thus valuable collaborators. However, doctors  and pharmacists alike revealed have revealed the time burdens, including schedule coordination, as a challenge.

Development of medication adherence forms, hard copy or integrated into pharmacy software, is a mechanism to quickly fax or electronically send an alert to patients’ healthcare providers that inadequate health literacy or lack of illness and medication therapy knowledge was identified. The low-time-consuming alert can open a channel of communication and collaboration between the pharmacist and healthcare provider to improve patient health literacy and medication adherence. (When RxLive partners with a practice, our clinical pharmacists send an easy-to-read provider takeaway document for them to review, uploaded directly into the practice’s EHR after every patient consultation.)

Summary: Literacy a strong predictor of health

Health literacy is a strong predictor of health, and pharmacists are crucial to improving medication adherence in regards to this component of the Understanding and Knowledge bucket. Identification of inadequate health literacy is the initial opportunity to address medication adherence at the pharmacy level. We recommend creating a trusting, shame-free environment, employing EDGE tactics with teach-back, offering plain-language written materials, and collaborating with providers to help enable patients be adherent to their medication regimen by building their health literacy and illness and medication therapy knowledge.


Adult Literacy in America. National Center for Education Statistics

Closing the Loop: Physician Communication with Diabetic Patients Who Have Low Health LiteracyArch Intern Med

Everyday Words for Public Health Communication. CDC

Facilitating Collaboration Between Pharmacists and Physicians Using an Interactive Interview Process. J Am Pharm Assoc

Health Literacy. Health Resources & Services Administration (HRSA)

Health Literacy: A Prescription to End Confusion. The Institute of Medicine

Health Literate Care Model. U.S. Department of Health and Human Services

Health Literacy: The Gap Between Physicians and Patients. Am Fam Physician

Improving Adherence Through Patient Health Literacy. Amerisource Bergen

Improving Health Literacy Could Prevent Nearly 1 Million Hospital Visits and Save Over $25 Billion a Year. United Health Group

Low Medication Knowledge and Adherence to Oral Chronic Medications among Patients Attending Community Pharmacies: A Cross-sectional Study in a Low-Income Country. BioMed Research International

Relationship Between Patients’ Knowledge and Medication Adherence Among Patients with Hypertension. Patient Prefer Adherence

Relationship of Functional Health Literacy to Patients’ Knowledge of Their Chronic Disease. Arch Intern Med

Shame and Health Literacy: The Unspoken Connection. Patient Educ Couns

Talking Points About Health Literacy. CDC

The Contribution of Health Literacy to Disparities in Self-rated Health Status and Preventative Health Behaviors in Older Adults. Annals of Internal Medicine

Use of a Modified Informed Consent Process among Vulnerable Patients: A Descriptive Study. J Gen Intern Med.

Author avatar
Kristen Engelen, PharmD
Kristen Engelen, PharmD, is the chief pharmacy officer of RxLive and a certified consultant pharmacist; she has over a decade of experience in retail pharmacy settings. Kristen became an RxLive co-founder because of her passion for geriatric pharmacy, with a focus on the intersection of pharmacy and aging.