#3102 LIMITED PHARMACEUTICAL LITERACY IN PATIENTS ON HEMODIALYSIS IN THE NETHERLANDS AS ASSESSED WITH THE RALPH INTERVIEW GUIDE
Authors: van den Oever Francisca , Vasbinder Erwin , Schrama Yvonne , Koster Ellen , Van den Bemt Patricia , Van Gelder Teun 
Published: June 2023

Abstract

Background and Aims
Patients with advanced chronic kidney disease typically use 15 or more different drugs. Proper use of these drugs requires sufficient pharmaceutical literacy, which is defined as health literacy in the context of medication use. Until now, no data are available on the prevalence of limited pharmaceutical literacy in patients with CKD or on hemodialysis. Recently, the RALPH (Recognizing and Addressing Limited Pharmaceutical Literacy) interview guide was developed in the Netherlands to assess pharmaceutical literacy skills. The current study aims to provide data on the prevalence of limited pharmaceutical literacy, associated problems, and the domains in which these problems occur, in hemodialysis patients using phosphate-binding drugs in the Netherlands.

Method
This study was part of a prospective observational study in a teaching hospital in Rotterdam, investigating a complex adherence-improving intervention in hemodialysis patients using phosphate-binding drugs. One of the aims of the original study was to explore pharmaceutical literacy at baseline, using the RALPH interview guide. The RALPH consists of eleven multiple-choice questions and several open-ended questions in three health literacy domains. The functional domain assesses the basic skills of reading, writing, and calculating. The communicative domain assesses more advanced skills, namely finding and understanding information and applying this information to the own situation. The critical domain assesses the even more advanced skills of critically analyzing information and applying this information to different situations. Limited pharmaceutical literacy was defined as the presence of at least one problem in one or more of the domains of the RALPH. The primary outcome was the prevalence of limited pharmaceutical literacy. Secondary outcomes were the prevalence of one or more problems in the domains. Data were analyzed using descriptive statistics (SPSS version 28.0).

Results
A total of 63 patients were included in the study. Mean age was 66 years, 65% were male. The main primary renal diagnoses were hypertensive nephropathy (31%) and diabetic nephropathy (19.1%). Seventy-three percent of patients received their drugs in a weekly drug dispensing system. The prevalence of limited pharmaceutical literacy was 79%. Fifty-two percent of patients had at least one problem in the communicative domain, 46% in the functional domain, and 78% in the critical domain. Around 90% of patients could correctly reproduce user instructions for phosphate-binding drugs. The most prevalent problems were lack of knowledge about the indication (40%) in the functional domain and finding understandable information (51%) in the communicative domain. In the critical domain, the most frequently encountered problems were a lack of adequate judgment of both reliability and applicability of information (62% and 65%, respectively). Almost half of the patients did not search for information. Furthermore, 32% of patients did not engage in shared-decision making or found this difficult to do. Reasons for this were a profound trust in the nephrologist and the patient's conviction that the nephrologist knew what was best.

Conclusion
Limited pharmaceutical literacy is frequent in patients on hemodialysis: the majority of patients have problems with finding understandable information and judging its applicability and reliability. The results of this study are in line with earlier findings studying pharmaceutical literacy in Dutch community pharmacies in the Netherlands. However, the current study found slightly higher percentages for problems with finding understandable information and judging the applicability of information. This was expected, as our population generally uses more drugs and has a more vulnerable health status. Recent data show that limited health literacy in general negatively affects certain aspects of self-management, such as adherence, communication, and knowledge. This is also apparent in our study. These data together underline the need for dialysis healthcare providers to individualize their communication and support to meet their patients’ needs.