BOSTON – Lack of health literacy, lack of routine, and being a nonnative speaker of English were predictors of treatment nonadherence in one-quarter of adults with hepatitis B virus in Australia, according to a study.
“Clinicians don’t know this is happening. We overlook it. Because it’s just one tablet a day, we think it’s quite easy, but when I took up this project, I completely underestimated the complexity of adherence and how many different factors can play into why a patient does or doesn’t adhere,” Suzanne Sheppard-Law, RN, MPH, PhD, a senior research fellow at the University of Technology Sydney, said in an interview about her prize-winning poster presentation at this year’s annual meeting of the American Association for the Study of Liver Diseases.
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The findings grew from Dr. Sheppard-Law’s clinical practice where she noticed a trend in some patients whose treatment regimen would lose efficacy over time. When switched to other therapies, the pattern would be repeated. Dr. Sheppard-Law interviewed 29 of these patients in person to see if there were commonalities she could address.
“The deeper I dug, the more it all unfolded before me,” she said. It turned out that patients who’d been endorsing adherence were not. In some cases, patients were skipping their medications for days at a time.
This informal study lead to a more formal one focused on a patient’s level of health literacy. Dr. Sheppard-Law and her colleagues examined factors the World Health Organization says are implicated in adherence, including ones that are social and economic, and others that are related to clinical worker interactions, health systems, individual therapy and condition, and patient considerations. They conducted in-person interviews and worked with the patients as they completed the Newest Vital Sign health literacy survey online.
Just over a fifth of respondents said they followed a regular routine when taking their medication, such as taking it at a certain time every day; however, three-quarters of those surveyed said they didn’t think having a routine made any difference (P less than .001). Half of respondents were prescribed at least one additional daily medication to their antiretroviral pill. A third had no idea what type of medication was prescribed for their hepatitis B.
Whether the person was proficient in English, and the impact this had on perceived communication between the patient and clinician was another factor, as most of the patients in the study were immigrants to Australia who’d been living there, on average, about 19 years. Only 27% of the study group reported that they spoke English at home as their primary language.
“It has to be individually focused, person-centered care, is the conclusion I came to,” Dr. Sheppard-Law said. Although her findings do not indicate a need for more resources in the clinic, she did say that clinicians could help patients by asking them to repeat back to them what they have heard.
“I don’t believe it has to be more resource intense; you just need to be sure the patient understands at the beginning what they need to do. Then you have a better chance [they will adhere],” she said. Because patients with poor health literacy are unlikely to tell their clinician that they do not fully grasp what they are being told about their condition and their treatment, Dr. Sheppard-Law suggested asking patients at the end of their consultation to detail what their routine will be, what they will do if they lose their prescription, what they will do if they run out of medication, and asking if they understand that their medication must be taken daily. “They need to understand it’s not okay to skip a day,” she said. “It’s our responsibility to ensure they know that.”
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