Race and Medicine Genetic studies of population differences, although controversial, promise David Goldstein of University College in clues to disease as well as new drug targets, scientists believe London agrees: "If you say on average the difference between West Africans and Eu- Mention race and medicine in a group of racial identity biologically irrelevant. But ropeans is slight, that does not rule out a
Healthliteracy.trinityseven.bizHealth Literacy FEATURE When most people think of literacy they think of reading and writing skills.
However, in Ireland, the National Adult Literacy Agency (NALA) is
working with a broader understanding and definition of adult literacy. Here,
Communications Officer with NALA, Jennifer Lynch details NALA's role in
the area of health literacy and explains the implications for Irish society.
Literacy involves listening and speaking, reading, writing, formulation in the adult literacy sector in Ireland. Since 2001
numeracy and using everyday technology to communicate NALA has developed HSE funded initiatives to address and handle information. It includes more than the technical health literacy issues. The Health Promotion Strategy 2000- skills of communication: it also has personal, social and economic 2005 (DOHC) acknowledged literacy as a barrier to accessing dimensions. Literacy increases the opportunity for individuals health information and work in this area has been driven by the to reflect on their situation and initiate change. This definition Population Health Unit. acknowledges that the literacy demands of society are constantly Currently health literacy is getting attention internationally changing. In our day to day lives we are being asked to use in terms of research and strategies. In April 2009, helped by a more paperwork and embrace technology for more and more National Lottery contribution from the Department of Health things, such as checking in our luggage or using our bank. and Children, Ireland agreed to participate in the first European Evidence shows that healthcare systems in industrial nations are Health Literacy Survey. The EU Health Literacy survey will also getting more complex and therefore more demanding for collect data on health literacy using standard methodology and patients (OECD 2005).
provide a comparative assessment of health literacy in the general public. NALA hopes that the results from this survey will The National Adult literacy Agency (NAlA) stimulate policy and research. The National Adult Literacy Agency (NALA) is a non-profit As part of its Health Literacy Policy, NALA seeks to make membership organisation concerned with training and policy the Irish health service literacy friendly where both the skills of October 09 THE CONSULTANT 51 consultant.indd 51 29/09/2009 15:40:39 "Health literacy emerges when the expectations, preferences and skills of individuals seeking health information and services meet the expectations, preferences and skills of those providing information and services." (IOM, 2004) This definition calls for a more balanced approach to analysing health literacy. It acknowledges that service providers contribute to the problem of health literacy and therefore have a part to play in making information and services more accessible. People who do not experience literacy difficulties in other areas of life might easily run into trouble in healthcare settings because they are not used to the setting or indeed the vocabulary used. They can struggle to make sense of health-related materials with unfamiliar concepts. Emotions can also play a part. When people feel vulnerable and scared their ability to understand information is inhibited. People sometimes have to make decisions in unfamiliar circumstances, where studies indicate that the dialogue is often fast and patients have limited speaking turns.
literacy in Ireland The first Irish literacy survey took place in 1995 with results published in 1997. It is called the International Adult Literacy Survey (IALS) and was sponsored by the Organisation for Economic Co-operation and Development (OECD). It took place across a number of international countries thus allowing for international comparisons. It used everyday reading material such as train timetables and instructions on a packet of Aspirin. It used a 5 Level scale with Level 3 considered the minimum level needed to actively engage in Irish society. Results showed that 25 per cent of the Irish population, or at PICTURED: Alice Leahy, Director of Trust and overall winner of the Crystal least 500,000 adults, scored at the lowest level, Level 1. This Clear Health Literacy Awards. Also pictured are Mr Neil Boyle, Managing means that a large percentage of the population experience Director of MSD Ireland and Jennifer Lynch of NALA.
difficulty with everyday reading material. People at this level }As part of its Health Literacy Policy, NALA seeks to make the Irish health service literacy friendly where both the skills of individuals and the literacy demands of the health service are analysed." individuals and the literacy demands of the health service are for example were not able to follow instructions on an everyday analysed. It wants to see a health service where literacy is not a health medicine, i.e. on a packet of Aspirin. People were asked barrier to treatment. It will work to influence the health service to look at the directions on this bottle to find "the maximum in every context: promotion, protection, prevention, access to number of days a person should take this medicine". A total of care and maintenance.
23 per cent of Irish adults (24 per cent male and 21 per cent female) could not answer this correctly. What is health literacy? Health literacy is a relatively new term. The USA Institute of Numeracy Results Medicine (IOM) and the Department of Health and Human Risk, probability, likelihood, norm are difficult mathematical Services offers the most relevant definition in emphasising a dual concepts and yet are commonly used in everyday communication, responsibility for health literacy: particularly in the healthcare context. Many of these concepts 52 THE CONSULTANT October 09 consultant.indd 52 29/09/2009 15:40:40 Health Literacy FEATURE are abstract and so people can have problems picturing and the body the "Cardiology Department" was for understanding them. • 10 per cent admitted to taking the wrong dose of medication Ireland did not score very well when answering the on one occasion because they could not fully understand "quantitative literacy" (numeracy) questions in the IALS. Again the directions.
25 per cent of people scored Level 1 meaning that they could not answer correctly the simplest of numerical questions with 41 What Can be done? per cent of these respondents in this group aged 56-65.
NALA would encourage all health organisations to use the HALA/HSE Literacy Audit for healthcare settings along with hidden Nature of literacy the eight minute health literacy awareness DVD. Both resources Many adults with weak literacy skills try to hide it. There is also were produced so that health practitioners could examine how the complication that people with weak literacy skills do not literacy friendly their settings are and begin to develop a health always realise their limitations. Adults who experience problems literacy plan. These resources explain good communication with literacy may: practice based on international practice and research.
• Appear passive or may act defensively• Pretend to have forgotten their glasses so as to avoid reading • Pretend to have hurt their hand so as to avoid writing in public. ( NALA 2002) NALA's research found that healthcare workers interviewed were not aware of literacy being an issue in Ireland and were not aware of their local literacy provider.
Approx 20 per cent of Irish people do not fully understood information and instructions that appeared on medication packaging." Irish Research in health literacy In 2007 the first national health literacy questionnaire was undertaken on behalf of Merck Sharp & Dohme Ireland (Human Health) Limited. Members of the general public were questioned about their interactions with medical practitioners and their understanding of medical terminology. The following are some of the key findings from the research:• 20 per cent of Irish people, do not deem themselves to be fully confident when dealing with medical professionals • Nearly 50 per cent of those surveyed stated that if they did not understand something a healthcare professional said to them they would only sometimes ask for clarification • Approx 20 per cent of Irish people do not fully understood information and instructions that appeared on medication • Nearly 67 per cent of those surveyed admitted to having difficulty understanding signs and directions in Irish hospitals at least some of the time, with one in five stating difficulty most of the time • 60 per cent of participants were unable to correctly define the • 20 per cent were not able to correctly identify which part of October 09 THE CONSULTANT 53 consultant.indd 53 29/09/2009 15:40:41 FEATURE Health Literacy NALA also recommends the use of ‘Ask Me 3' and ‘Teach Back' initiative to meet with healthcare professionals, politicians and systems. ‘Ask Me 3' encourages patients to ask three questions of the Minister for Health, Mary Harney. Dr Rudd explained their healthcare provider: how health literacy has had a positive effect on public health Life with epilepsy can be much more than just a gap bet ween seizures* • What is the main problem? in other countries. Rudd is a Senior Lecturer on Society, • What do I need to do? Human Development and Health at the Harvard School of Public Health and she has been involved in the development • Why is it important for me to do this? of health policies for the US Office of Disease Prevention and In the ‘Teach Back' method, the healthcare provider asks the Health Promotion, the NIH Oral Health Division, and the patient to repeat instructions to ensure that the message has National Institutes of Sciences. Commenting on Ireland she been relayed accurately. Health workers are advised to place the noted that there seemed to be a general interest in the area but responsibility on themselves to make sure they are understood a literacy champion has yet to emerge – and the topic needs a e.g. "I want to be sure I explained everything properly because champion. According to Dr Rudd the US Surgeon-General was this can be confusing. Can you tell me what changes we decided a champion of this in the US – you need policy people to step to make and how you will take your medication now?" up and say this is important and you need professional societies In 2008 NALA and MSD organised the first health to incorporate these presentations, to encourage research and to literacy awards, the Crystal Clear Awards, to encourage put in requirements both for education in terms of qualifying healthcare professionals and organisations to consider how they degrees and also for continuing education for practitioners. Dr communicate health matters to the public by acknowledging best Rudd highlighted the 2007 US Joint Commission White Paper practice in this area. Efforts such as this develop an awareness on Health Literacy which stated, "Failure to provide patients with of health literacy amongst health practitioners and can help to information about their care in ways that they can understand, will develop communication standards. continue to undermine other efforts to improve patient safety." health literacy in the US For more information on this subject please contact Jennifer In February of this year, Dr Rima Rudd was invited to Ireland Lynch, NALA Project Co-ordinator at [email protected] or visit
by Merck Sharp and Dohme, as part of their MSD/ NALA Add Vimpat® for the confidence of additional seizure control u An innovative mode of action1,2 u Improved seizure control, compared to or regardless of current or prior antiepileptic drug therapy3 u High long-term retention rate4 Licensed for adjunctive therapy in patients with partial-onset seizures ≥16 years old Confidence of additional seizure control ABBREVIATED PRESCRIBING INFORMATION
cipients. Known second- or third-degree atrioventricular block. In addition prolongation may occur. Consult SPC in relation to other side effects. (Please consult the Summary of Product Characteristics (SmPC) before pre- for tablets, hypersensitivity to peanuts or soya. Precautions: Lacosamide Pharmaceutical Precautions: Tablets: None. Syrup: Do not store above
has been associated with dizziness. Use with caution in patients with known 30°C. Use within 4 weeks of first opening. Solution for infusion: Do not VIMPAT 50 mg, 100 mg, 150 mg and 200 mg film-coated tablets, VIMPAT 15
conduction problems, severe cardiac disease or in elderly. Excipients in the store above 25°C. Use immediately. mg/ml syrup, VIMPAT 10 mg/ml solution for infusion
syrup may cause allergic reactions (possibly delayed), should not be taken Legal Category: POM. Product Licence Numbers: 50 mg x 14 tabs:
Active Ingredient: Tablets: lacosamide 50 mg, 100 mg, 150 mg and 200
by those with fructose intolerance and may be harmful to patients with phe- EU/1/08/470/001; 100 mg x 14 tabs: EU/1/08/470/004; 100 mg mg film-coated tablets. Syrup: lacosamide 15 mg/ml. Solution for infusion: nylketonuria. Monitor patients for signs of suicidal ideation and behaviours. x 56 tabs: EU/1/08/470/005; 150 mg x 14 tabs: EU/1/08/470/007; lacosamide 10 mg/ml. Advise patients and carers to seek medical advice should such signs emerge. 150 mg x 56 tabs: EU/1/08/470/008; 200 mg x 56 tabs: Therapeutic Indications: VIMPAT is indicated as adjunctive therapy in the
Interactions: Prolongations in PR interval with lacosamide have been ob- EU/1/08/470/011; Syrup (15 mg/ml) x 200 ml: EU/1/08/470/014; treatment of partial-onset seizures with or without secondary generalisation served in clinical studies. Use with caution in patients treated with products Solution for Infusion (10 mg/ml) x 20 ml: EU/1/08/470/016. in patients with epilepsy aged 16 years and older. Dosage and Administra-
associated with PR prolongation and those treated with class I antiarrhyth- Name and Address of PL Holder: UCB Pharma S.A., Allee de la Recherche
tion: Adults and adolescents from 16 years: Recommended starting dose
mic drugs. Strong enzyme inducers such as rifampicin or St John's Wort 60, B-1070 Bruxelles, Belgium. Further information is available on request
is 50 mg twice a day which should be increased to an initial therapeutic may moderately reduce the systemic exposure of lacosamide. No significant from: UCB Pharma Ireland Ltd, United Drug House, Magna Drive, Magna
dose of 100 mg twice a day after 1 week. Maximum daily dose of 400 mg effect on plasma concentrations of carbamazepine and valproic acid. La- Business Park, Citywest Road, Dublin 24. (in two 200 mg doses). For solution for infusion: Infused over a period of cosamide plasma concentrations were not affected by carbamazepine and Tel: 01 4637395. Fax: 01 4637396.
15 to 60 minutes twice daily. Can be administered i.v. without further dilu- valproic acid. No clinically relevant interaction with ethinylestradiol and tion. Elderly: No dose reduction necessary. Age associated decreased renal levonorgestrel. No effect on pharmacokinetics of digoxin. Pregnancy and Date of Revision: February 2009. VIMPAT is a registered trade name.
clearance with an increase in AUC levels should be considered. Paediatric Lactation: Should not be used during pregnancy. For precautionary mea- References: 1. VIMPAT® Summary of Product Characteristics, June 2008. 2.
patients: Not recommended. Patients with renal impairment: No dose ad- sures, breast feeding should be discontinued during treatment with lacos- Beyreuther BK et al. CNS Drug Rev 2007; 13(1):21-42. 3. UCB data on file. justment necessary in mild and moderate renal impairment. Dose adjustment amide. Driving etc.: Patients are advised not to drive a car or operate other 4. Rosenfeld W et al. Poster presented at the 61st Annual American Epilepsy is recommended in SPC for patients with severe renal impairment and pa- potentially hazardous machinery until they are familiar with the effects of Society Meeting November 30 – December 4, 2007. Ref *: Ben-Menachem tients with end-stage renal disease. Dose titration should be performed with VIMPAT on their ability to perform such activities. Adverse Effects: Very com- et al, Epilepsia, 48(7): 1308-1317,
caution. Patients with hepatic impairment: No dose adjustment needed in mon (≥10%): Dizziness, headache, diplopia, nausea. Common (between mild to moderate impairment. In accordance with current clinical practice, 1%-10%): Depression, balance disorder, abnormal coordination, memory if VIMPAT has to be discontinued, it is recommended this be done gradually impairment, cognitive disorder, somnolence, tremor, nystagmus, blurred vi- Date of preparation: February 2009
(e.g. taper the daily dose by 200 mg/week). Contraindications, Warnings
sion, vertigo, vomiting, constipation, flatulence, pruritus, gait disturbance, 08VIM239
etc.: Contraindications: Hypersensitivity to lacosamide or to any of the ex-
asthenia, fatigue, fall, skin laceration. Adverse reactions associated with PR 54 THE CONSULTANT October 09 consultant.indd 54 29/09/2009 15:40:44
MINAG-IICA BORRADOR DE TRABAJO1 INFORMACION BASE PARA LA ELABORACION DE UN PROGRAMA DE APOYO A LA AGROINDUSTRIA Y A LA AGROINDUSTRIA RURAL EN Pj. Zela S/n Jesús María Telf. 433 2899 SETIEMBRE DEL 2,005 1 Siendo este documento un Borrador de Trabajo, agradeceremos las colaboraciones encaminadas a