Mitigating low health literacy

Lead by Nandini Ray

Patients living with common conditions such as hypertension, hyperlipidemia, diabetes mellitus, and thyroid disorders, amongst other chronic comorbidities, often require a higher level of routine care in the healthcare setting to help coordinate medication management and follow-up appointments. Unfortunately, patients who are unable to successfully interpret health information often experience worse health outcomes, including increased hospitalization rates, advanced disease burden, and increased morbidity and mortality. Low health literacy is often associated with patients who are older, have limited education, lower income, and undertreated comorbidities, amongst other social burdens. Low health literacy is also a major problem among people from rural and inner-city communities. This patient demographic is more likely to utilize emergency department care and sometimes even free clinic services, with poor follow-up and compliances with medications. The Lubbock Impact Free Clinic in Lubbock, Texas, is a student-run free clinic that provides health care and interdisciplinary services to the underserved population of the Lubbock and surrounding communities. To mitigate the ongoing issue with low health literacy amongst the patient population being served there, a project was undertaken with Nandini Ray being the project principal. For patients whom the clinic cared for routinely, we noticed a lack of compliance with medication regimens and the occasional missed clinic appointment. Upon further exploring some of these barriers to care with the patients during clinic visits, we started to understand that these patients had a limited understanding of the magnitude of their underlying comorbidities. Some patients did not fully understand why certain treatment regimens are pursued. This limited health comprehension amongst patients often led to an incomplete understanding of the effects of not taking thyroid medications and antidepressant medications on a disciplined basis for the best possible outcomes or not completing the full course of antibiotic therapy to avoid complications such as antibiotic resistance. Therefore, as a first step, a Medication Instruction Sheet to distribute at the Free Clinic that included one page of special directions for common medications for common chronic conditions such as diabetes, hypertension, hyperlipidemia, hypothyroidism, major depressive disorder, anxiety, asthma, and gastroesophageal reflux disease, amongst others, was created. The second page included a table adapted from the U.S. Food and Drug Administration for each patient’s medication regimen with columns entitled, “What I’m Using,” “Why I’m Using This,” “How Much,” “How to Use/When to Use,” and “Start/Stop Dates” to help patients better keep track of their medications. Distributing this document to patients during clinic visits at The Lubbock Impact Free Clinic and taking the time to walk them through their home medication regimens helps make a difference in improving overall patient outcomes.

Special directions for common medications

Diabetes	High Blload Pressure/Cholesterol
Test blood sugar as directed and keep a log book of results to bring to your next appointment Metformin: take with meals, swallow whole - If you experience diarrhea, you may use loperamide (imodium) Injecting Insulin: Inject right under the skin in the stomach area (2 inches away from the belly button), thigh/buttock, or back of the upper arm Stay in the same general area but ROTATE the location where you inject Sliding Scale Insulin Therapy Eat pre-set amount of carbohydrates at each meal and at a similar time of day Basal insulin dose: take the same long-acting insulin dose no matter the blood glucose level Bolus insulin dose: take according to blood sugar level before a meal/bedtime	Check your blood pressure as directed, keep a log book to bring to your next visit Limit sodium and alcohol along with foods/drinks with added sugar ACE inhibitors: lisinopril, enalapril, etc. Take on an empty stomach one hour before meals Notify your doctor if you develop a bad dry cough Calcium channel blockers: nifedipine, amlodipine, etc. Avoid grapefruit juice Diuretics/water pills: furosemide, hydrochlorothiazide, etc. Take in the morning with food
Pain	Thyroid
Acetaminophen (Tylenol): no more than 2 grams per day NSAIDs (Advil, Ibuprofen, Naproxen, Aleve): Don’t take with aspirin Do not take these on an empty stomach; always take with food Talk to your physician about prolonged NSAID use (>30 days)	Levothyroxine: take at the same time every day with a full glass of water Take at least 1 hour before you eat or 3 hours after you eat Don’t take calcium or iron within 4 hours of taking your thyroid medicine Do not take over-the-counter thyroid supplements
Antibiotics	Antidepressants
Finish the entire course and don’t share your medications Take with food to avoid having an upset stomach One-time dose of an antibiotic at the clinic (Ceftriaxone) along with a prescription for additional antibiotics After completing the entire course of medication, refrain from sexual activity for the next 7 days	Take at least 30 second breaks in between multiple puffs and shake well before each use Clean the inhaler at least once a week and rinse mouth following each use Symbicort/long-acting inhalers: will not work fast to treat an asthma attack Take everyday to prevent asthma/control chronic asthma May take up to 1 week for symptoms to improve Ventolin/short acting inhalers: used for potential asthma attacks Take a dose 15-30 mins before exercise and physical activity Effects should last for 4-6 hours
Birth Control	Asthma
Start pills on the Sunday after your first day of your menstrual period Spotting/nausea may occur during when starting or skipping any pills If you have nausea, take the pill with food Progesterone: take at same time every day (within the same 3 hours every day to be protected from pregnancy) Combination pills: take at the same general time every day Tip: set an alarm on your phone or take the pill in the morning/at bedtime while brushing your teeth	Take at least 30 second breaks in between multiple puffs and shake well before each use Clean the inhaler at least once a week and rinse mouth following each use Symbicort/long-acting inhalers: will not work fast to treat an asthma attack Take everyday to prevent asthma/control chronic asthma May take up to 1 week for symptoms to improve Ventolin/short acting inhalers: used for potential asthma attacks Take a dose 15-30 mins before exercise and physical activity Effects should last for 4-6 hours
Acid Reflux/GERD	General Instructions
Avoid lying down immediately after meals and eating late at night Limit consumption of foods that might irritate your stomach: alcohol, chocolate, caffeine, citrus fruits or soda H2 inhibitors (pepcid, zantac, cimetidine, famotidine, ranitdine): take before meals, preferably in the morning	Take your medications exactly as prescribed. Don't skip doses. Tell your provider about all additional medications you're taking. If you have any questions or concerns, contact the Free Clinic