Medication Literacy in a Cohort of Chinese Patients Discharged with

Essential Hypertension

Zhuqing Zhong

1,2

, Siqing Ding

, Shuangjiao Shi

1,3

, Zehua Xu

and Aijing Luo

1,2,*

Third Xiangya Hospital, Central South University, Changsha 410013, China

Key Laboratory of Medical Information Research, Central South University,

College of Hunan Province, Changsha 410013, China

Xiangya Nursing School, Central South University, Changsha 410013, China

Keyword: Essential Hypertension, Discharged Patients, Medication Literacy, Medication.

Abstract: To assess medication literacy and important determinants of medication literacy in discharged patients with

essential hypertension, we conducted a prospective cohort study in a tertiary hospital in Changsha, Hunan,

China between March and June 2016.Patient’s demographic and clinical data were retrieved from hospital

charts and medication literacy was measured by structured interview using the Chinese version of Medication

Literacy Questionnaire on Discharged Patient between 7 and 30 days after discharged. The results showed

that medication literacy was insufficient: > 20% did not have adequate knowledge on the type of drugs and

frequency that they need to take the drugs, > 30% did not know the name and dosage of the drugs they are

taking, and > 70% did not have adequate knowledge on the effects and side effects of the drugs they are

taking. Medication literacy score decreased with age but increased with education level and length of hospital

stay.

1 INTRODUCTION

With an aging population, chronic non-

communicable disease, led by hypertensive disorders,

has become China's number one health killer (Hu et

al., 2015). On the other hand, the proportion of

awareness and preparedness, treatment compliance,

and well-controlled patients affected by hypertension

in China have been at very low levels (Chen et al.,

2015). Self-treatment and self-medication in patients

affected by hypertension without appropriate medical

supervision were prevalent, and lack of continuation

in care and problem arising from multi-drug use were

widespread in China (Hu et al., 2010). More

importantly, these patients often lack knowledge of

appropriate and safe use of anti-hypertensive drugs,

so the hypertensive patients have become high risk

group of adverse drug events (Hughes et al., 2013).

Therefore, the safety of self-medication of patients

with hypertension has become a major concern in

China. Medication literacy refers to the ability of

individuals to acquire and understand drug

information and to use this information for safe and

appropriate use of medications (Sauceda et al., 2012;

Corresponding author

Zheng et al., 2015 ） . Interventions aiming at

improving medication literacy level for patients

affected by chronic hypertension have been

considered as one of the effective methods to improve

self-medication safety (Raynor., 2008; Raynor.,

2009). According to the Annual Report of

cardiovascular diseases in China in 2015, there were

270 million hypertension patients in the country (Hu

et al., 2015). The prevalence of hypertension was

65%, it costs 40 billion yuan each year (Chen et al.,

2015). For patients with hypertension, long-term,

regular, and correct use of medication is critical to

reduce the occurrence of major cardiovascular events

(Kripalani et al., 2008). Studies in China found that

the medication use of among hypertension patients

was often inappropriate or problematic (Hu et al.,

2015). A recent survey in China found that the

proportion of inappropriate use of anti-hypertensive

drugs was very high among outpatients affected by

essential hypertension: of the 102 surveyed patients

68 (67%) took these medications inappropriately

(Peng et al., 2013). In this study, we further

investigated this issue in a cohort of hospitalized

patients affected by essential hypertension in China.

216

Zhong, Z., Ding, S., Shi, S., Xu, Z. and Luo, A.

Medication Literacy in a Cohort of Chinese Patients Discharged with Essential Hypertension.

DOI: 10.5220/0007307102160220

In Proceedings of the 12th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2019), pages 216-220

ISBN: 978-989-758-353-7

2 EXPERIMENTAL SECTION

2.1 Participants

Patients diagnosed with essential hypertension and

admitted to the Third Affiliated Xiangya Hospital of

Central South University in Changsha, Hunan, China

between March and June 2016 were invited to

participate. Inclusion criteria were (1) age ≤ 85 years

of age with competent language communication

ability; (2) taking anti-hypertensive drugs ≥ 2 weeks;

(3) mentally stable; (4) voluntarily participating in the

study under the principle of informed consent.

Exclusion criteria were (1) mentally unstable or major

mental disorder; (2) major chronic diseases such as

chronic obstructive emphysema, severe hepatic or

renal insufficiency. We obtained ethical approval

from third Xiangya Hospital, Central South

University Research Ethics Board to conduct this

study (project identification code: 2016-S001) before

the commencement of the study and all participants

provided written informed consent.

2.2 Data Collection

Medication literacy was measured by the Chinese

version of Medication Literacy Questionnaire on

Discharged Patient developed by Maniaci from Mayo

Clinic in the United States (Maniaci et al., 2008). This

questionnaire has been translated into Chinese and

modifications have been made according to Chinese

culture (Zheng et al., 2015)

The questionnaire

attempts to evaluate the patient’s ability to

understand, calculate, and process pharmaceutical

information. The questionnaire contains 9 items and

uses a dichotomy scoring system, with a correct

answer for a score of “1” and an incorrect answer for

a score of “0”. At discharge the attending doctor

provided instructions of the prescribed drugs to the

patients, including the names, dosage, frequency of

use, therapeutic effects, and main side effects. We

compared the patient’s answers to the doctor’s

instructions and if the answer was right one score was

given and if the answer was incorrect no score was

given. Item 7 has only a “Yes” or “No” answer and

item 9 has only specific names. Therefore, item 7 and

item 9 contribute no score towards total score. As a

result, the full score of this questionnaire is 7, with a

higher score indicates higher level of medication

literacy. For individual patients, the possible score is

0 to 7 without decimals, with 0 means all answers are

incorrect and 7 means all answers correct. The

Cronbach’s α coefficient of the Chinese version of

questionnaire content was 0.85, validity index was

0.81, and retesting reliability coefficient was 0.94

(Zheng et al., 2015).

On the discharge date, patient’s demographic and

clinical data such gender, age, education level,

medication, and length of hospital stay were retrieved

from hospital charts. Between 7 and 30 days after the

patient was discharged from the hospital, staff at the

research team made telephone calls to the patients to

collect data on medication literacy.

2.3 Data Analyses

Means, standard deviations (SDs), and percentages

were used to describe the patient’s baseline

characteristics and medication literacy level. T-test

was used in the univariate analysis and multiple linear

regression analysis was used to analyse the

independent effect of determinants of medication

literacy. Full model with all determinants considered

in this study being entered into the multiple linear

regression model. SPSS version 19.0 (2010, New

York, NY, USA) was used in all analyses.

3 RESULTS

3.1 Medication Literacy

A total of 147 discharged patients with essential

hypertension were invited to participate in this study,

5 patients refused to participate in the study and 10

patients did not complete the questionnaire, leaving

132 (91%) for final analysis. Among the 132 patients,

62 were male and 70 were female. Means (SDs) of

patient’s age were 59.4 (15.7) years, number of

medicines that the patients were taking at discharge

were 4.4 (2.2), and hospital days were 8.1 (3.7).

Details of the medication literacy for this cohort

of discharged patients with essential hypertension are

displayed in Table 1. In brief, mean (SD) of

medication literacy score was 4.89 (1.28). Although

all patients knew that they should take medicines after

discharge from hospital, only 55.3% of them knew

how many medicines they should take on daily basis,

43.9% could name the medicines they were taking,

and about 28% knew the effects and side effects of

the medications they were taking.

Medication Literacy in a Cohort of Chinese Patients Discharged with Essential Hypertension

217

Table 1: Medication literacy for discharged patients with

hypertension, Changsha, Hunan, China, March to June

2016 (n = 132).

Items

Number

Correct

Answer

Proportion

(%)

1. Did you take

medicines after you

were discharged from

hospital?

132

100.0

2. How many kinds of

medicine did you need

to take every day?

55.3

3. Did you know the

names of the medicines

that you are taking?

43.9

4. Did you know the

dosage of the

medicines that you are

taking?

65.9

5. Did you know how

many frequent you

should take the

medicines?

131

99.2

6. Did you know the

effects of every

medicine that you are

taking?

128

97.0

7. Have you ever been

warned of the side

effects of the medicines

that you are taking?

16.7

8. Did you know the

side effects of the

medicines that you are

taking?

28.0

9. Did you know whom

you should consult with

in case of questions

related to the medicines

you are taking?

Local doctors

24.2

Doctors who give the

prescription

38.6

Pharmacist

4.5

I don’t know

26.5

Others

6.1

3.2 Determinants of Medication

Literacy

Table 2 shows the results of univariate analysis. Four

factors were significantly associated with medication

literacy, with higher scores observed in male,

younger, highly educed patients, and patients who

took a lower number of medicines at discharge.

Table 3 presents results from multiple linear

regression analysis. Three factors showed

independent association with medication literacy,

with medication literacy scores decreased with age

but increased with education level and prolonged

hospital stay.

Table 2: Results of univariate analysis of determinants of

medication literacy for discharged patients with

hypertension, Changsha, Hunan, China, March to June

2016 (n = 132).

Variable

Name

Mean (SD) of

Total Score

T/H

Age

4.078

0.000

<65years

5.23±1.30

≥65years

4.35±1.05

Gender

0.759

0.449

Male

4.81±1.27

Female

5.60±0.97

Year of

schooling

≤ 6 years

7-9

10-12

>12

4.08± 0.97

4.81±1.24

4.98±1.26

5.76±1.18

7.550

0.000

Marital

status

2.526

0.084

Married

4.93±1.29

Unmarried

4.30±0.95

Number of

medicines

taken at

discharge

-0.257

0.798

≤7

4.87±1.29

5.00±1.22

Length of

hospital stay

-2.153

0.033

≤8 days

4.72±1.26

>8 days

5.22±1.26

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Table 3: Results of multiple linear regression analysis of

determinants of medication literacy for discharged patients

with hypertension, Changsha, Hunan, China, March to June

2016 (n = 132).

Determinants

Age (each 10

years)

-0.022

0.009

0.018

Education (each

year of

schooling)

0.428

0.159

0.008

Hospital stay

(each day of

stay)

0.059

0.027

0.030

4 DISCUSSIONS

Our study, based on a cohort of discharged patients

with essential hypertension, found that medication

literacy for these patients was insufficient: > 20% did

not have adequate knowledge on the types of drugs

that they need to take the drugs, > 30% did not know

the name of or the dosage of the drugs they are taking,

and > 70% did not have adequate knowledge on the

effects and side effects of the drugs. As a result, it is

critical to improve health literacy of these patients in

China as improved literacy could improve medication

adherence and therefore outcomes. Our study also

found that age, education, hospital stay was

independently associated with medication literacy

level.

Medication literacy level decreased with age in

our study sample. This result was consistent with the

finding of previous studies (King et al., 1998; Choi.,

2011; Zamora., 2011)

The cognition of elder patients

may be poorly, therefore their ability of learning and

memory may be not as good as younger patients. Our

results indicated that high education was associated

with a better literacy level. This was inconsistent with

Mania et al (Maniaci et al., 2008). The positive

correlation between education status and medication

literacy level suggested that literacy ability could help

in better understanding of medication information

and health issues, and therefore enhancing the

medication literacy. The positive association between

hospital stay and the level of medication literacy is

interesting and is first reported by us. We speculate

that during longer the patients stay in hospital, the

more health information including both hypertension

and anti-hypertensive drugs they gained, which

translated to medication literacy.

Lack of medication literacy exposed the

hypertension patients to increased risks of re-

hospitalization, emergency department visits, or

serious consequences due to adverse events related to

unsafe medication (Toren et al., 2006; Sarkar et al.,

2011). Effective communication on medication

between patients and health care professionals is an

important way to improve medication literacy (Choi.,

2011; Yedidia et al., 2003)

and it is the key to

decrease the medication errors. Verbal

communication with physicians, patients could not

remember detailed medication information and

counselling well, so providing comprehensive written

material on medication education for patients is

another important method. Meanwhile, follow-up

after discharge could remind patients to pay more

attention to their medication. Our study has several

strengths. First, although studies on medication

literacy for patients discharged with hypertension

have been conducted in other populations, to the best

of our knowledge, this is the first study that has

measured the medication literacy and examined the

determinants of medication literacy in discharged

hypertension patients in a Chinese population.

Because of the important differences in culture and

health care systems in China as compared with other

populations/jurisdictions, a study in the Chinese

population is needed. Second, we used a validated

tool to measure medication literacy, which lends

validity to the study results. Third, patients surveyed

in this study had homogeneous condition with

accurate diagnoses by a tertiary care centre in China,

which lends further validity to the study findings.

Fourth, the collected data were analysed by solid

statistical methods with results easy to be interpreted.

Limitations of our study should be recognized.

First, our data were collected only from a single

hospital in Changsha, Hunan. To what extent the

results can be applicable in other jurisdictions need to

be replicated. Second, we used the same tool to access

the participant with different ages, which may not be

appropriate for certain age groups.

5 CONCLUSIONS

Medication literacy is insufficient for hospitalized

patients affected by essential hypertension. Age,

education, and hospital stay are important

determinants of medication literacy, with medication

literacy level decreases with aging but increases with

education level and hospital stay.

Medication Literacy in a Cohort of Chinese Patients Discharged with Essential Hypertension

219

AUTHOR CONTRIBUTIONS

Zhuqing Zhong designed the study, participated the

data processing and statistical analysis, and wrote

initial draft of the manuscript. Feng Zheng and

Yinglong Duan participated in the design of the study

and questionnaire administration and discussed

analytical results. Siqing Ding provided important

feedback on the manuscript. Aijing Luo participated

in its design and provided important feedback on the

manuscript. All authors read and approved the final

manuscript.

CONFLICTS OF INTEREST

The authors declare no conflict of interest.

FUNDING

This study was supported by a grant from Natural

Science Foundation of China (Grant No. 71603290).

ACKNOWLEDGMENTS

We thank the patients and staff at the Third Affiliated

Xiangya Hospital of Central South University for

their support of this study. Shi Wu Wen of the

University of Ottawa provided advice on statistical

analysis and results interpretation.

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