The importance of health literacy for rational pharmacotherapy of seniors in home care

Introduction

Health literacy, as a new term introduced in the 1970s, is increasingly important for public health and healthcare (Beňadiková, Boriková, 2020). It is characterized as the ability of an individual to obtain, process and understand basic information about health and health services, which is necessary for making correct decisions regarding his health (Mrázová, Mráz 2022, p. 7). Currently, it is considered one of the ways to prevent health problems and protect health, but also how to organize unexpected situations or problems related to health (Čakloš, Bóriková, 2020).

In the case of seniors, it is the ability to understand instructions aimed at the implementation of preventive activities and cooperation in the treatment of diseases.

However, at an older age, health literacy can be affected by various factors (internal, external, influenceable, non-influenceable). Factors that significantly influence health literacy/ability to understand information include:

• changes in the aging process – with increasing age and a decline in the cognitive abilities of an elderly person, the inability to understand new topics or recall or remember them increases significantly (Magerčiaková, 2022),
• impaired function of sensory organs - vision, hearing,
• polymorbidity, combination of several therapeutic procedures, polypharmacy (which are also barriers to education) (Zrubáková, Bartošovič, 2019),
• rapid development of technology, new aids, technical devices,
• digitization in healthcare, changes in the provision of healthcare and social services (Beňadikova, Bóriková, 2020, Novysedláková, Hudáková, 2012, Suri, 2014).

Another problem can be the more frequent isolation from normal social life, which makes it more difficult to provide up-to-date information in a targeted manner, as well as to increase health literacy in general. According to Mrázová, Mráza (2022) it is also the previous knowledge, abilities, skills and also the environment in which they make these decisions.

In order to preserve health, functional capacity and maintain an adequate quality of life, it is important that seniors have information and improve their health literacy, especially in the following areas:

• prevention of acute diseases, complications of chronic diseases or syndromes.
• Organization and functioning of health care systems.
• Non-pharmacological treatment procedures - rehabilitation, activation, medical nutrition, hydration, phytotherapy (Sedova et al, 2016).
• Pharmacological treatment, use of medicines, vitamins and nutritional supplements.

Pharmacological treatment belongs to the area that is a priority in older age. Pharmacotherapy is also the most common method of treatment. According to scientific studies and our own research, only 10% of old people living at home do not take any medicine, on average they use 5 medicines (Zrubáková, Krajčík et al., 2016, Bartošovič et al. 2023). In connection with older age, certain complications are also associated with it. The main risks of pharmacological treatment include:

• increased number of drugs (polypharmacy, polypharmacy ↑ 5 drugs),
• predominance of symptomatic treatment over causal treatment,
• high risk of adverse effects - with atypical clinical manifestations,
• drug-drug, drug-food, drug-food supplement interactions,
• peculiarities of pharmacokinetics and pharmacodynamics,
• negative impact on the quality of life - unwanted effects of drugs (Krajčík, Dúbrava, Bartošovič, Mikus et al. 2022).

Health literacy and pharmacotherapy

Aspects of the understanding of medicines include knowledge about the indication of the medicine, dose, frequency and, for certain categories, also special instructions for taking the medicine (taking it before a meal, after a meal, with a time interval after another medicine...) or interactions, e.g. with food. For seniors with polymorbidity, the correct understanding and adherence to the treatment process is more than crucial for the successful control of the disease and clinical results. Research, but also their own clinical experience, point to the fact that seniors often do not fully understand the instructions for the safe and effective use of medicines, they do not understand the terms in the package leaflet (Novysedláková, Hudáková, 2012). Advanced age and impaired cognitive abilities adversely affect the understanding of drug treatment instructions (Green, 2022). Disorders of sensory functions - vision, hearing negatively affect the perception and processing of verbal or written information. Fine motor disorders make it impossible to properly prepare and apply medicines (Zrubáková, Krajčík, 2016). Health literacy and cooperation of seniors is influenced by the social environment and demographic characteristics (Sedova et al, 2016). It is scientifically confirmed that the level of health literacy of seniors living at home is lower compared to other age categories (Hung et al, 2018).

Negative of low level of understanding of information on pharmacological treatment

If a senior/geriatric patient does not have enough information about the current treatment, it causes a number of complications, which are processed in Table 1.

Tab.1 Consequences of low health literacy

Pharmacotherapy of seniors at home

To compare data obtained from scientific and professional documents, we conducted research in the home environment of seniors.

The main goal of the research was: to find out the level of health literacy of seniors in the selected locality.

We have also defined sub-goals of the research:

1. find out what are the current problems in connection with pharmacotherapy for seniors in the community,
2. to find out the level of knowledge of seniors about the use of medicines,
3. compare the level of knowledge in terms of demographic characteristics (location, gender, age, number of medications),
4. find out what problems in connection with pharmacotherapy digitalization has caused in the health sector.

Research File

The research group consisted of seniors/geriatric patients living in the community, Nové Mesto nad Váhom and Ružomberok districts. The research group consisted of 107 seniors living in their households in the cities of Ružomberok and Nové Mesto nad Váhom, the villages of Liptovská Lúžna, Liptovské Sliače, Liptovská Osada, Čachtice, Višňové, Bzince pod Javorinou. The average age of seniors was 74.6 (Tab.2). The percentage representation of women in the group was 69% (Tab.3). Primary and apprenticeship education prevailed among the respondents - together it was 79%. According to marital status, the majority of respondents were married couples - 55%. Seniors mostly lived in the family home. The number of members in the household was on average 2 - husband or children. The least was 1, most often a woman living alone. At most 5 - widowed mother/father and children with family. Tab. 2 Average age of respondents

Tab. 3 Gender of respondents

Research methods

The research methods were semi-structured interview and observation. In a semi-structured interview, we focused the questions on the number of drugs, identification of inappropriate drugs, quality of prescription, occurrence of adverse drug effects, information about therapy (oral, written), buying over-the-counter drugs, visiting a doctor, level of doctor-specialist cooperation, as well as problems of pharmacotherapy (health, adverse effects of drugs) and problems related to electronic prescription of drugs, appointments for examinations, etc. We recorded the answers to the questions in the prepared sheet - Tab. 4.

Tab. 4 Transcription of the interview into the specified categories

The interview took place in the home of seniors, with their informed consent. We conducted one-off and, if necessary, repeated interviews.

During the observation, we focused on 4 categories: I. household condition, II. storage of medicines, III. method of preparation of medicines, IV. the use of aids in the administration of medicines. We entered the obtained data into the prepared electronic sheet.

Research Results

The first set of questions in the semi-structured interview was about the number of medicines and the seniors' knowledge about them. Regarding the number of medications, we also focused on the occurrence of polypharmacy (use of 5 or more medications/treatment methods at the same time), which, as we have already mentioned, is the cause of a reduced level of health literacy. We found that 36 respondents (41%) regularly used more than 5 medicines. On the contrary, 2 respondents (men) stated that they do not take any medication regularly. Table 5 shows the average number of medications by age category and district.

Tab. 5 Average number of medicines for individual age categories

The above table also shows that the number of medications increases proportionally with age, as the number of chronic diseases that require pharmacological treatment increases.

When evaluating the medication knowledge questions, we found that:

• 47% of seniors have knowledge about medicines. They knew what medicines they were taking, they knew the indication group and the main effect. Only 11 (9.7%) respondents had insufficient knowledge. The cause of insufficient knowledge was: large numbers of medicines (5 or more). When there were more seniors, they no longer remembered what the "medicines are" for and what the doctor and pharmacist told them. The second leading cause was mild cognitive impairment and neurological disease. In both districts, there were seniors after a sudden stroke, p. Parkinson's disease, their knowledge was low. Pharmacotherapy was provided by a family member or caregiver. In exceptional cases, lack of knowledge was also caused by the lack of interest of seniors - especially among men living alone. It manifested itself in other areas as well (mistakes in the use of medicines, occasional alcohol consumption, which we present in the following text).
• 50% know the adverse effects of the drugs they use, 27% of seniors could not answer.

By evaluating category B, we identified the main problems of pharmacotherapy. We were based on the knowledge that the problems are related to the drug itself (size, packaging, interactions, unwanted manifestations...), to the patient-senior and health workers (Zrubáková, Krajčík, 2016). Drug-related problems included adverse effects/health problems. 59 seniors answered that medicines cause them health problems, their specification is given in Tab.6.

Tab.6 Health problems of seniors

Problems related to the use and handling of the medicinal product were reported by 30 respondents. We present the answers in order:

1. Consumption of medicines.
2. Difficulty swallowing.
3. Poor handling of drops.
4. Poor "peeling" from the packaging.
5. Selection of medicines.

The second circle concerned the drug users themselves and their cooperation/compliance with pharmacotherapy. According to the information obtained, we can conclude that only 39% of seniors take medication according to the doctor's instructions. 57 seniors - 53% of respondents admitted to mistakes (Tab.7).

Tab. 7 Mistakes when taking medicines

| Errors in the use of medicines Number of seniors n | | --- | --- | | I forget to take the medicine 31 | | I don't have the right drink | 1 | | I do not follow the dosage and method of use 7 | | I do not take all medicines | 4 | | I adjust my treatment according to my state of health | 8 | | I drink alcohol during treatment 6 | | Together | 57 |

As the numbers in the table show, the most common mistake was not taking the medicine because the senior would forget it. This answer was given by seniors with a larger number of prescribed drugs or when a new drug was prescribed.

Another mistake was buying over-the-counter drugs without having their suitability assessed by a doctor or pharmacist. The most frequently purchased drugs were: analgesics, antipyretics, antidiarrheals, ointments, drugs recommended by acquaintances and after reading the leaflet about the drug in the pharmacy. These data were given mainly by women, aged 65-74, living in both district towns (the larger number was in Nové Mesto nad Váhom).

Digitalization in the healthcare sector is currently a problem for seniors.**

• Only 11 seniors stated that they had a problem with the electronic prescription of medicines.
• A larger number - 32 expressed concern about errors in repeated prescriptions.
• 61 seniors need help in making an electronic appointment for a check-up with a specialist doctor.

Health literacy is also closely related to the method of obtaining information about the medicine/medicines. Therefore, we focused most of the questions on the provision of information by healthcare workers, their own activities, such as obtaining information about medicines, the way of acquiring knowledge. We found that:

• Seniors most often obtain information from a doctor (generalist, specialist, geriatrician), regarding the use of the drug, its effect or adverse effects. When given orally, however, they do not remember all the information, sometimes they need the presence of a family member - daughter, son, daughter-in-law.
• Seniors feel more confident when they have the information about the medicine written down, or have a list of medicines, a breakdown of usage.
• Reading the package leaflet for a new drug affects the scope of the text and the list of adverse drug effects. They do not understand technical terms.
• They also get information from leaflets in the pharmacy, they notice advertisements in magazines and on television.
• Sometimes they look for information on the Internet.
• Women were more interested in information regarding treatment options for their own or their husband's medical condition.

Table 8 shows the answers regarding the interest of seniors in obtaining information.

Tab.8 Interest in information on pharmacotherapy

According to the given numbers, we can conclude that almost half of the 48% of respondents are very interested in information. On the other hand, 31% are not interested in information. This data has a negative impact on cooperation in treatment and the implementation of rational pharmacotherapy.

Results of the observation method

At the same time, participant observation helped us to obtain a comprehensive overview of the factors threatening rational pharmacotherapy, according to previous research (Zrubáková, Krajčík, 2016), the most common include:

• low level of social relations, inappropriate adjustment of the home environment,
• incorrect storage of medicines (Tab.9), unsuitable medicines in the medicine cabinet, expired and redundant medicines,
• problems when taking medicines, mistakes when preparing medicines,
• not using aids that prevent medication errors.

Tab. 9 Errors in the storage of medicines

The results from Table 9 also indicate the level of health literacy in pharmacotherapy. If a senior/drug user does not have comprehensive information about the drug, which also includes the method of storage, he may devalue it by placing it inappropriately. When objectifying the data, we further discovered that seniors made the following mistakes:

• ointments and suppositories were not stored in the refrigerator,
• medicines were exposed to direct sunlight,
• the temperature in the room was more than 25 degrees Celsius (when visiting the household in the summer months).

It was positive to find that not a single household had seniors "stocked up" with medicine. They only had a maximum of two packs of prescribed medication. However, they often had an excess of analgesics, anti-constipation drugs and unsuitable nutritional supplements in their medicine cabinets. In the same way, seniors minimally used aids facilitating the administration of medicines - a dispenser, a medicine bottle, an electronic medicine dispenser. They do not use the possibility to add medicines, warnings about use, through the mobile phone application at all.

Discussion

According to the principles of modern geriatrics, the home environment is the ideal environment for a senior, but it is also associated with a certain risk. As we found out when processing the research results, it is highly risky when implementing rational pharmacotherapy. The reason may be changes resulting from the aging process, but also poorer access to health care. Old people have a problem with visiting a medical facility, a specialist clinic, in community care there is very little assistance from medical personnel (mainly ADOS nurses) when administering medicines. "This has an impact on two facts: the regular control of the use of medicines and the administration of medicines more complex than pill forms" (Krajčík, Dúbrava, Bartošovič, Mikus et al., 2022).

When analyzing the results of the research, we can state that we have identified several problems - a large number of drugs, occurrence of polypharmacy, polypharmacy, problems related to the use of drugs, non-compliance, lack of interest of patients and problems related to care providers. Cooperation and, at the same time, the level of health literacy were influenced by medical conditions, the number of medications, but also the willingness of the senior to obtain information, to be interested in his health condition and to fulfill the recommendations of the doctor, nurse and other team members. It is also stated in the professional literature... the characteristic features of compliance in older age consist mainly in the fact that the senior is very interested in his health, treatment and his willingness to cooperate with the doctor is high, about 70% of patients are willing to follow the treatment exactly, and the majority of seniors are competent to rationally cooperate in treatment (Dúbrava, 2006, p. 331). According to the current study by Green (2022), the level of health literacy is related to the health status, education and personality characteristics of seniors. Participants in excellent health reported higher levels of resource awareness and perceived treatment effectiveness than participants in poor or good health. In addition, participants with a university degree understand online information better than participants with a high school education. The dimensions of health literacy influenced the participants' personal health knowledge.

Conclusion

Health literacy is more than health education, it is achieved by methods that go beyond the passive reception of information because it includes interactions, participation and critical analysis (Čakloš, Bŕiková, 2020). In the case of pharmacological treatment, it is important for the elimination of errors and the occurrence of adverse effects and drug interactions. Health literacy could be one of the ways to prevent health problems, protect health and eliminate polypharmacy, but also to solve unexpected situations or problems that affect the condition and treatment of seniors/geriatric patients, especially in community care.

Author: PhDr. Katarína Zrubáková, PhD. Faculty of Health Sciences, University of Ružomberok

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