**3. Impacts of poor health literacy of medication adherence**

Most of the time medication dispensers think that patients understand the instructions given to them regarding their medications but that is not always the case. Health literacy regarding medication instructions is a subject on its own, which needs to be unpacked. Health literacy do not always need basic literacy skills, if the individual understands the clock she or he is covered.

#### **3.1 Misconception and misunderstanding**

Misconception or misunderstanding could lead patients to non-adherence to their medication. Diabetes mellitus patients had misconception and misunderstanding regarding the prescribed medication instructions [19]. The instructions did not have specific times at which medications should be consumed. The instructions on the medication packages are not adequate; for instance, the instructions were written as morning, noon, night, or two times a day etc. [20]. This kind of instructions may be dangerous because patients with poor health literacy would interpret them wrongly [20]. Patients end up with drug toxicity or underdose. Patients also had incorrect perception of the medication instructions where the patients do not fully understand the instructions [21].

#### **3.2 Non-compliance**

One of the major problems responsible for non-adherence is the fact that patients esteem themselves as understanding the instructions. Diabetes mellitus

**277**

*The Importance of Health Literacy Related to Medications Instructions to Promote Adherence…*

patients perceived themselves as understanding the medication instructions which is however contrary to how they "actually" carried them out [19]. Understanding medication instructions means taking medication correctly and that includes taking the correct dose, at the right frequency, being persistent and consistent [21]. Non-adherence is linked to increased health services utilisation and frequent hospitalisation [22]. Many of the diabetes mellitus patients demonstrated a knowledge discrepancy concerning medication use during disease treatment [23]. This lack of knowledge can aggravate the health state of people with diabetes mellitus. Subsequently, bring about a momentous increase in direct and indirect health costs. Non-compliance is often coupled with patient's negligence. Diabetes mellitus patients often drink too much alcohol and when drunk, do not take their prescribed medications. Similar situation is recorded in [24] where non-compliance was linked to patients not giving attention to their health with double increase in

On the contrary, most patients were non-compliant because they had poor health literacy either because of shallow explanations given by health professionals or the unclear medication instructions on medication packages, leaflets or doctor's

Professional nurses as medication dispensers at primary health care level need to give a full explanation of the medication instructions to the patients. *(Refer to Table 3).* Diabetes mellitus patients do however indicate that they do not get such explanations as expected. **Participant 'G'** *when asked to share how she was told to take their medications said, "No. They have never explained well to me, but they said I should take the medication in the morning, during the day, and when I go to sleep".* **Participant 'E'** also said, *"They said I should take the medication the way they are; but for the times and hours no. They just* 

In other words, patients do adhere to what the professional nurses tell them however, that information given to them is incomplete. This incomplete explanation

The medication instructions on the leaflets, packaging, and doctors' prescrip-

*3.2.2 Unclear medication instructions on medication packages, leaflets or doctor's* 

tions are not clear. There is a poor explanation of the time-frequency on the documents' medication instructions. **One drug is written as**, *"1mg once daily".* **Another one is written:** *"One 500mg tablet 2 to 3 times a day".* There is no time interval reflected on the doctor's prescription, medication leaflets, and packaging. The drugs are written as follows: *"One 850mg tablet twice a day".* **Another drug is written, "***40 to 80mg daily".* **Whereas another one is written**, *"Daily doses over 10mg in 2 divided doses". there are no specific times for taking medication on diabetic medication instruction documents. One drug is written as, "Doses of 160mg daily in 2 divided doses". Another one is written: "Should be taken the same time every day".* The medication instruction does not specify the exact times for taking the medications. **One drug is written as,** *"Doses of 160mg daily in 2 divided doses".*

**Another one is written:** *"Should be taken the same time every day".*

Doctors should clarify medication instructions to patients and if they fail to do so, the pharmacists and professional nurses should, when dispensing 11]. If the health professionals fail, the last resort would be the medication packages and accompanying print materials like container labels, package inserts, medication

*DOI: http://dx.doi.org/10.5772/intechopen.95902*

non-compliance due to alcohol use.

*3.2.1 Shallow explanations by professional nurses*

*said in the morning, during the day, and at night".*

therefore contributes to patients not adhering to treatment.

prescriptions.

*prescriptions*

#### *The Importance of Health Literacy Related to Medications Instructions to Promote Adherence… DOI: http://dx.doi.org/10.5772/intechopen.95902*

patients perceived themselves as understanding the medication instructions which is however contrary to how they "actually" carried them out [19]. Understanding medication instructions means taking medication correctly and that includes taking the correct dose, at the right frequency, being persistent and consistent [21]. Non-adherence is linked to increased health services utilisation and frequent hospitalisation [22]. Many of the diabetes mellitus patients demonstrated a knowledge discrepancy concerning medication use during disease treatment [23]. This lack of knowledge can aggravate the health state of people with diabetes mellitus. Subsequently, bring about a momentous increase in direct and indirect health costs.

Non-compliance is often coupled with patient's negligence. Diabetes mellitus patients often drink too much alcohol and when drunk, do not take their prescribed medications. Similar situation is recorded in [24] where non-compliance was linked to patients not giving attention to their health with double increase in non-compliance due to alcohol use.

On the contrary, most patients were non-compliant because they had poor health literacy either because of shallow explanations given by health professionals or the unclear medication instructions on medication packages, leaflets or doctor's prescriptions.

#### *3.2.1 Shallow explanations by professional nurses*

Professional nurses as medication dispensers at primary health care level need to give a full explanation of the medication instructions to the patients. *(Refer to Table 3).* Diabetes mellitus patients do however indicate that they do not get such explanations as expected. **Participant 'G'** *when asked to share how she was told to take their medications said, "No. They have never explained well to me, but they said I should take the medication in the morning, during the day, and when I go to sleep".* **Participant 'E'** also said, *"They said I should take the medication the way they are; but for the times and hours no. They just said in the morning, during the day, and at night".*

In other words, patients do adhere to what the professional nurses tell them however, that information given to them is incomplete. This incomplete explanation therefore contributes to patients not adhering to treatment.

## *3.2.2 Unclear medication instructions on medication packages, leaflets or doctor's prescriptions*

The medication instructions on the leaflets, packaging, and doctors' prescriptions are not clear. There is a poor explanation of the time-frequency on the documents' medication instructions. **One drug is written as**, *"1mg once daily".* **Another one is written:** *"One 500mg tablet 2 to 3 times a day".* There is no time interval reflected on the doctor's prescription, medication leaflets, and packaging. The drugs are written as follows: *"One 850mg tablet twice a day".* **Another drug is written, "***40 to 80mg daily".* **Whereas another one is written**, *"Daily doses over 10mg in 2 divided doses". there are no specific times for taking medication on diabetic medication instruction documents. One drug is written as, "Doses of 160mg daily in 2 divided doses". Another one is written: "Should be taken the same time every day".*

The medication instruction does not specify the exact times for taking the medications. **One drug is written as,** *"Doses of 160mg daily in 2 divided doses".* **Another one is written:** *"Should be taken the same time every day".*

Doctors should clarify medication instructions to patients and if they fail to do so, the pharmacists and professional nurses should, when dispensing 11]. If the health professionals fail, the last resort would be the medication packages and accompanying print materials like container labels, package inserts, medication

*Lifestyle and Epidemiology - The Double Burden of Poverty and Cardiovascular Diseases...*

to give out to the patients to reference at home *(see appendix 1*).

newspapers, for health information [16]. These defective sources mostly lead individuals into making erroneous verdicts about their health. The patients should be taught how to seek credible information sources on the media. There should be ever-ready more specific and detailed health information materials

7.**Inadequate patient education related to medication use -** Research has also shown that medication non-adherence and treatment ineffectiveness can be negatively influenced by the inability to comprehend medication instructions. The problem is not with patients using medications only but also dispensing health practitioners and medication manufacturers. Most of the generally used medication label instructions are unclear, and misunderstanding takes place also in highly educated patients [17]. Poor understanding of medication instructions or misinterpretations could be a cause for patients not using their medications as prescribed. Misinterpretation of medication instructions leads to subprime medication therapy resulting from consuming less than instructed, getting insufficient medication concentrations, or increased risks of adverse effects by overdosing and medication concentration increasing interactions.

It is evident that inadequate health literacy hinders patients' understanding of medication instructions [18]. The instructions also could be written in the clearest and specific manner, however, there is limited evidence supporting the best practices for writing prescription medication instructions to enhance patients' comprehension for proper use of the medication. Therefore, a more specific wording should be used on prescription medication instructions to enhance patients'

Most of the time medication dispensers think that patients understand the instructions given to them regarding their medications but that is not always the case. Health literacy regarding medication instructions is a subject on its own, which needs to be unpacked. Health literacy do not always need basic literacy skills,

Misconception or misunderstanding could lead patients to non-adherence to their medication. Diabetes mellitus patients had misconception and misunderstanding regarding the prescribed medication instructions [19]. The instructions did not have specific times at which medications should be consumed. The instructions on the medication packages are not adequate; for instance, the instructions were written as morning, noon, night, or two times a day etc. [20]. This kind of instructions may be dangerous because patients with poor health literacy would interpret them wrongly [20]. Patients end up with drug toxicity or underdose. Patients also had incorrect perception of the medication instructions where the

One of the major problems responsible for non-adherence is the fact that patients esteem themselves as understanding the instructions. Diabetes mellitus

**3. Impacts of poor health literacy of medication adherence**

if the individual understands the clock she or he is covered.

patients do not fully understand the instructions [21].

**3.1 Misconception and misunderstanding**

**276**

**3.2 Non-compliance**

comprehension [18].

*Lifestyle and Epidemiology - The Double Burden of Poverty and Cardiovascular Diseases...*


**Table 2.**

*The symptoms experienced by diabetes mellitus patients on treatment.*

guides etc. however, the print materials have been found to be complex and written in medical language which patients do not understand irrespective of their literacy level [25]. Most the patients on diabetes medications are elderly. It will serve us right as health professionals to write or tell the patients the exact times for taking the medications. This should also include the rationale for doing so. That is, to avoid over- or under-medicating themselves.

### **3.3 Complications**

Non-compliance due to poor literacy result in some patients experiencing complications. Most of the patients experiencing complications do not know that they are linked to the disease process and non-adherence. Patients who were not compliant experienced complications compared to those who are compliant [26]. Some of the complications experienced by diabetes mellitus patients on prescribed medications are listed on **(Table 2)**. For erectile dysfunction, women were excluded.
