Health literacy intervention in Khayelitsha to address community medication sharing

Health in Context: Health Promotion Protocol

Ashleigh Dwarika, Sameenah Hashim, Matthew Leppan, Letang Matlala, Nathan Morar ,Nobuhle Ndhlovu, Noxolo Ndzoyiya, Bjorn Sorensen, Kelly

Sweatman

Contents

Plagiarism declaration:........................................................................................................................2

Authors..................................................................................................................................................3

Acknowledgements...............................................................................................................................3

Abstract.................................................................................................................................................4

Introduction...........................................................................................................................................5

Health promotion activity......................................................................................................................6

Process by which problem for health promotion was identified.......................................................6

Literature review...............................................................................................................................6

Aim..................................................................................................................................................10

Objectives........................................................................................................................................10

Ottawa charter actions....................................................................................................................10

Community participation.................................................................................................................11

Policy...............................................................................................................................................11

Behaviour change theories and approaches applicable in this project............................................12

Planning, design and pre-testing.....................................................................................................13

Messages are distributed through various forms of media i.e. TV and radio. Choosing the medium is therefore an important decision. This decision will depend on the aims and budget..................13

Different educational and mass media approaches.........................................................................13

Role of advocacy..............................................................................................................................15

Stakeholder involvement.................................................................................................................16

Reflections...........................................................................................................................................17

Health rights and ethical principles.....................................................................................................17

Conclusion and recommendations......................................................................................................18

References:..........................................................................................................................................20

Plagiarism declaration:

Names (student number):

Ashleigh Dwarika (DWRASH003), Sameenah Hashim (HSHSAM001), Matthew Leppan (LPPMAT001), Letang Matlala (MTTLET007), Nathan Morar (MRRNAT004), Nobuhle Ndhlovu (NDHNOB001), Noxolo Ndzoyiya (NDZNOX002), Bjorn Sorensen (SRNBJO001), Kelly Sweatman (SWTKEL001)

Course: MBChB

Declaration

We know that plagiarism is wrong. Plagiarism is to use another’s work and pretend that it is one’s own.

We have used the VANCOUVER convention for citation and referencing. Each contribution to, and quotation in, this Health in Context Research Protocol from the work(s) of other people has been attributed, and has been cited and referenced.

This Health in Context Research Protocol is our own work.

We have not allowed, and will not allow, anyone to copy our work with the intention of passing it off as his or her own work.

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Date: 27 March 2017

Authors

Policy

Bjorn Sorensen

Kelly Sweatman

Behaviour change theories

Letang Matlala

Nathan Morar

Planning, designing, and pretesting of mass media

Ashleigh Dwarika

Sameenah Hashim

Matthew Leppan

Role of advocacy

Nobuhle Ndhlovu

Noxolo Ndzoyiya

Acknowledgements

Site facilitator: Mrs Tsuki Xapa

Key Stakeholder: Mr Kholweni

Hosts of intervention: Meals on Wheels, Zibonele Radio Station

Abstract

Introduction: The sharing of medicine has been identified as a significant health problem in

Khayelitsha. This behaviour is believed to stem mainly from a lack of health literacy around the

dangers of sharing medicine. Other reasons for sharing medicine are long waiting times in the clinics

and the attitudes of health workers. The aim of this health promotion campaign is, therefore, to

educate the community of Khayelitsha on the risks of chronic medication sharing through the

development of educational messages and their distribution using various media forms. Additional

goals of this campaign are to address policy issues that result in inefficiency of clinics and hospitals

and attempt to change the community’s perception of health workers.

Planning the campaign: A community stakeholder and other members of the Khayelitsha community

were involved in identifying and prioritising the issue of medicine sharing, as well as planning the

campaign. Various health promotion tools, such as behaviour change theories, were incorporated

into the planning of the campaign.

Health promotion activities: An interactive radio talk show was delivered by Radio Zibonele that

delivered various education messages about medicine sharing and allowed members of the

community to call in to have their questions and concerns addressed. Posters with detailed

information on medicine sharing were designed and will be put up at Meals on Wheels and finally an

educational skit about the dangers of sharing medicine was performed at Meals on Wheels.

Conclusions and recommendations: Not only was lacking health literacy a cause of medicine sharing

but through community engagement additional reasons for people sharing medicine were identified

such as poor access to health care services, as well as health workers being perceived to have poor

attitudes.

It is important that this health promotion campaign is sustainable. The dramatization and radio

recording will be distributed on social media. In addition, the posters will remain at Meals on

Wheels. Finally, education of health workers on the importance of health literacy will also help

improve the problem of medicine sharing.

Introduction

According to the World Health Organisation (WHO), health promotion is the process of enabling

individuals to increase control over, and improve health1. Health literacy, a subheading of health

promotion, is an individual's ability to access, understand and act upon information to promote, and

maintain health2. It can be improved through health promotion interventions, where individuals are

provided with relevant personal, social and cognitive skills. There are many approaches to

interventions which are influenced and decided by relevant behaviour change theories. These

theories act on various levels; individual, interpersonal or community, and multiple theories can be

applied to a single intervention.

The literature indicates multiple socioeconomic factors that shape behaviours and affect health

literacy. Low levels of health literacy are associated with unhealthy behaviours, and poor health

outcomes such as increased mortality and/or morbidity 2. It is the health system's responsibility to

create and promote health literate environments by developing interventions, with varying effects,

and policies to address poor literacy.

Khayelitsha is a low-socioeconomic residential area in the Western Cape with significant disparities

regarding socio-economic factors. These disparities influence the health literacy of the residents 3, 4.

Factors such as low educational levels, occupation and low income negatively impact health literacy.

The stakeholder, Mr Kholweni runs the Meals on wheels NGO in Khayelitsha. This NGO provides

lunch time meals from a community centre as well as delivers meals to resident’s homes. Mr

Kholweni along with other community members, identified health literacy, specifically regarding

medication sharing as a prevalent issue. Due to the high prevalence of chronic disease in the area

people tend to self-diagnose and share medication amongst community members. Their reasons for

sharing medication included the inconvenience of long waiting times at clinics, inaccessibility of

healthcare services at night, a lack of time and/or money, and the assumption that medication is

safe to share. This issue was found to be of importance to us as it was a top priority for the

stakeholder, and is responsible for poor health outcomes that can be easily prevented.

This health promotion intervention was designed to improve health literacy in Khayelitsha by

decreasing sharing of medication. Information was provided to the target population by mass media,

radio, posters and a dramatization. The behaviour change theories applicable to this intervention are

the information processing paradigm and the theory of planned behaviour.

Health promotion activity

Process by which problem for health promotion was identified

Students met with stakeholders at Meals on Wheels. The stakeholders gave the students the topic of

health literacy. In the discussion, the prevalence of chronic medication sharing in the community

was stated. This issue was investigated through a literature review and student discussion. The

discussion yielded an idea of health education on medication sharing at Meals on Wheels and radio

Zibonele. After investigating the feasibility of this idea, it was decided to take this forward as the

intervention.

Literature review

Introduction

Peer reviewed published articles were reviewed to investigate health literacy and its association with

the sharing of medication.

The following search terms were used:

Pubmed: ("Health Literacy"[Mesh]) AND "Health Promotion"[Mesh]).

Google scholar: health literacy * AND sharing medication.

Health literacy is crucial in order to empower individuals and communities regarding health

decisions. It also helps to improve their access to health information and enables them to use this

information effectively 1 . Health literacy is used to educate society about common diseases,

preventative methods and treatment. This is achieved by strategies that are interactive and allow for

community participation e.g. health workshops at clinics and community centres 1.

Factors that affect health literacy include gender, age, race, and education level as well as household

income 5. Due to the legacy of apartheid in South Africa certain members were not afforded the

opportunity to education and other privileges which ultimately resulted in a vicious cycle of poverty.

Unfortunately, even with the cessation of apartheid, this cycle continues today with the result of

poor health literacy levels amongst the same previously oppressed groups.

The research articles show that there is an association with health literacy and health behaviour.

One of the areas which health literacy appears to be needed is in mitigating against inappropriate

sharing of medication. Sharing of medication amongst members with chronic health conditions can

result in adverse health effects on those taking the medication especially if the dosage and type of

medication is incorrect.

There are various methods that can be used to promote health and health literacy, namely

workshops at clinics and community centres, posters, radio and television adverts, and health

professionals being advocates of change for bad health behaviour.

The sharing of medication has been identified as a local issue in Khayelitsha, but there is limited local

and internationally research regarding it.

Factors associated with health literacy

Many demographic and socio-economic factor affected poor health literacy. These include; male

gender, older age, lower education level, and low household income 4, 5. Females also had higher

adequate literacy levels than males (42.4 % to 39.5 %). Other factors included race 5, marital

conditions 5, and suburban participants had lower scores than urban participants1.

Health literacy and health behaviours

In a systematic review of 11 articles, there was a statistically significant association between health

literacy and medication adherence (r <0.09, p <0.0001). A low health literacy level resulted in 52.2%

non-adherence compared to 19.5% in those with marginal health literacy. Low levels of health

literacy were associated with poor knowledge of HIV treatment and low self-efficacy for following

treatment regimen 3.

Health literacy and health outcomes

The aim of health literacy is to empower patients with sufficient information to make informed

decisions about their health. It was determined that 58% of patients seldom require help with

interpreting written medical information 6. This indicates that just less than half do not fully

understand written material which affects health behaviour and outcomes.

Health literacy is an issue for many people who are living with HIV (PLWH). PLWH with low health

literacy have lower CD4 +T cell counts, higher viral loads, decreased ART uptake, increased

hospitalizations and poorer health. They are also less likely to adhere to ART and have poor

understanding of HIV infection and the potential for progression if untreated 6.

Other research shows that improving health literacy of diabetes was effective in improving self-

management, diabetes knowledge, and HbA1c control in both adequate and limited health literacy

group 5.

Unhealthy behaviours and health literacy

There are two pathways that link health literacy with health status. One pathway intermediated by

health information access and another intermediated by health behaviour. Those with higher health

literacy as measured by the 14-item Health Literacy Scale (HLS-14) were significantly more likely to

get sufficient health information from multiple sources (p <0.0001), less likely to have risky habits of

smoking (p<0.001), regular drinking (p<0.001), and lack of exercise (p=0.050), and in turn, more

likely to report good self-rated health (p=0.048) 5, 7.

Medication sharing

An online survey using Irish students showed 26% reported borrowing, 20% reported sharing and

12% reported both sharing and borrowing prescription drugs, primarily to avoid the cost (37%), the

inconvenience of going to a doctor (22%) and not feeling sick enough to see a medical professional

(14%). Participants borrowed medicines from family (51.2%) and friends (18.2%). Those who

borrowed or shared prescription drugs believed they were at a lesser risk of side effects from taking

other people’s medicines (p < 0.0005, χ2 test) 8.

A similar trend was found in the United States, where 22.9% of 700 participants claimed to have lent

out prescription medication and 26.9% said they borrowed prescription medication 9.

Analgesics were found to be the most common self-administered drug. In a questionnaire and focus

group, 55% and 76% of participants respectively admitted to sharing prescription analgesics to which

their attitude was that it was normal. Potential negative effects were not a concern 10.

Minimal research regarding sharing of chronic medication in South Africa were found.

Interventions affecting health literacy

Various studies have been conducted to evaluate the effectiveness on interventions in improving

health literacy. One intervention was Text4baby where text messages were used to provide

educational messages to both pregnant and post-partum females. This was effective in improving

health literacy 11.

School-level education 12, 13 significantly enhanced knowledge surrounding pain medication and

allowed people to be more self-efficient in taking pain medication and improving long term mental

health literacy11, 12.

Group education sessions, providing specific individualized information, telephonic counselling and

assistance with attending health facilities i.e. appointment making, transport and translation

improved health literacy and health seeking behaviour 14.

Patient Information Leaflets (PIL) should be improved to promote health literacy. PIL are only useful

to literate people and only 10% of PIL promoted management of illnesses and healthy lifestyles 15.

Patients who take medication incorrectly often do so because they misunderstand the prescription

labels and the risk increased with decreased language proficiency. Labels that are easier to read,

have clear instructions, prioritise information with larger font and increase white space significantly

improved the use of the drug for English patients but not for Spanish patients 16.

Conclusion

Health literacy is determined by many socioeconomic factors and affects health behaviour and

outcomes. Interventions have been shown to have varying effects on health literacy, but can be

effective. The literature on medication sharing is predominately done in developed countries and it

is therefore difficult to extrapolate this data to South Africa, especially low socio-economic areas

such as Khayelitsha. Medication sharing and improving its associated health literacy may be an

important factor in improving health behaviour and outcomes.

Aim

To educate the community of Khayelitsha on the risks of chronic medication sharing.

Objectives

Create a health education intervention on chronic medication sharing.

Implementation of the intervention to improve health literacy and health outcomes.

Ottawa charter actions

Create supportive environments

During the planning of the intervention, the aim was to create effective community action 4, through

the education on the consequences of self-medication and self-diagnosis. This would promote

personal responsibility for community members to attend clinics and not share medication.

Hopefully, through the provision of information and the screening activities, community members

will feel empowered to take ownership and control of their health 4.

Develop personal skills

This intervention strives to support personal and social development1 through the provision of

health education. This was achieved through providing information in their first language, isiXhosa.

This would enable the community to fully understand the information and enable them to exercise

better control over their own health and environments and make choices conducive to their health 4.

Community participation

Prior to the intervention, the enthusiasm with which the stakeholders and community members

engaged showed a clear understanding of the major problems within the community. This made it

possible to plan and execute a successful and helpful intervention.

The community took well to the intervention. There were approximately 50 people in attendance

and community members actively participated. Many people volunteered to answer questions.

During the radio presentation there were many callers wanting to engage and ask questions. The

radio ensured a wide distribution of information. The community participation can be attributed to

the various forms of health promotion that was used in isiXhosa. The notable willingness of the

community to engage and participate made this intervention very successful.

Policy

The sharing of chronic medication is difficult to regulate using policy. Dispensing of chronic

medication is already tightly regulated. People however share medication regardless of the dangers

of running out before their next clinic appointment. The issue is the lack of health literacy within the

community. This is therefore a behaviour change and education issue and not one of inadequate

policy.

Looking into the reasons why people share medication, and developing policy around it, may be

useful. Reasons identified by members of the community include long waiting times at clinics. It was

the community stakeholders who identified medication sharing as an issue. Other stakeholders

involve doctors and pharmacists who prescribe and dispense medication. National managers will

ensure adequate resource allocation as well as the local clinic managers to ensure efficiency of the

clinics. In addition, a top-down approach which would also be required to address the fundamental

issues of poverty and inequality of access.

The South African government conceptualized The Ideal Clinic Initiative in attempt to achieve

efficiency, equity, effectiveness and quality in the healthcare system. Improving waiting times was

included in this. An eight month study was conducted to determine what factors would make clinics

ideal. The findings are intended to be implemented as part of the National Health Insurance policy.

The evaluation will be done by conducting a similar study in order to formulate policy as well as to

compare the results of the two studies 17.

Furthermore, HealthCare 2030, which is an official Western Cape Government document, aims

towards a more patient-centred system with improved access to quality care. Their vision includes

patients not having to wait for longer than reasonable. All patients will make appointments (except

in emergencies) and their files will be readily available for this reason.

The files will also be electronic which will further decrease waiting time. With the vision of such an

improved system, it is hoped that patients will be more satisfied; staff will be empowered, “the

community takes responsibility for its health” 18 and that the Western Cape Department of Health

runs a coherent and efficient health system and is corruption-free with their employees being

recognised and respected. The provincial government will mobilise other departments to improve

the health of society and address other social-determinants of health 18.

Behaviour change theories and approaches applicable in this project

Information processing paradigm:

The theory of information processing paradigm often works in relation to other theories. The theory

operates at an individual level and uses communication to persuade people to make healthy

behaviour changes. It is applicable to our intervention as it aimed to persuade people to stop

sharing medications, especially those for chronic conditions.

The three phases of message processing were followed throughout.

The first phase draws attention to the message. Posters were colourful and would attract attention.

Secondly, the presentation used a dramatization that depicted the dangers of medicine sharing. This

captivated viewers and illustrated the potentially fatal consequences. The dramatization was age

appropriate and wasn’t childish or undermined the information. The second phase speaks of

comprehensive content. Posters were in the participant’s first-language, isiXhosa, and translators

were used during the presentation. Furthermore, information was divided into subcategories

allowing for manageable portions as to not overwhelm the participants. Lastly, with acceptance of

the content, the participant’s socioeconomic difficulties and reasons for sharing medication were

acknowledged and this was considered in the intervention development. Practical information and

recommendations were used that were realistic in the participant’s socioeconomic context.

Theory of planned behaviour

This theory links beliefs and behaviour. It builds on the theory of reasoned action. The reasoned

action theory only includes attitude towards behaviour and subjective norms, and this theory adds

perceived behavioural control. These three factors contribute to behavioural intentions and

behaviour action 19.

The health promotion participants’ attitudes towards medication sharing were that sharing chronic

medication wasn’t dangerous. They weren’t aware of the dangers and believed chronic medication

to be freely usable between individuals. This was addressed by providing information on the dangers

of sharing common chronic medication.

The subjective norms were that chronic medication sharing was accepted and common in the

community. The majority of the community was unaware of the dangers and shared chronic

medication freely. This was addressed by providing information to change this common attitude.

Participants’ perceived behavioural control was evident as they were sharing medication.

Community members had medication to share and therefore the patients were able to freely

acquire medication in the community. This was not addressed because we do not want to restrict

medication access in the community. We rather encouraged participants to seek medical care and

acquire their own medication.

Planning, design and pre-testing

What makes a good health promotion campaign?

Health promotion campaigns involve two aspects. Firstly, developing the message and secondly

distributing the message 20.

When developing the message, there are important points to consider. Researching the problem is

important e.g. whether it is a communication problem. This could be targeted by educational

campaigns. The context of the participants involved must be understood. The target audience must

be known. The information must be evidence based. The information must be appropriate to media

e.g. not too long if on radio/TV. The nature of the message must; have the correct language, be

positive (positive messages are more effective), simple, and have a clear message 21.

Messages are distributed through various forms of media i.e. TV and radio. Choosing the medium is

therefore an important decision. This decision will depend on the aims and budget.

Different educational and mass media approaches

Our health promotion campaign made use of three forms of media, namely posters, radio and a

dramatization. This increased the distribution of the information and ensured the target audience

had repeated opportunities to grasp the health promotion message. Below we discuss each medium

that was used and evaluate its effectiveness in achieving the goals of the health promotion

campaign.

Posters

Posters are a positive medium through which to deliver health promotion information as they

enable detailed educational information to be shared. They can also be permanent/placed in a fixed

position which repeatedly exposes people to the information. Posters, however, need to attract

attention and be placed in effective positions.

Evaluation of posters

The posters were very effective. They were big, colourful, laminated (protected against damage) and

printed in isiXhosa – one the biggest advantages to our posters as this is the home language for

majority of the people in Khayelitsha, making them easily understood. They also contained more

information than what was delivered in the dramatization. This will enable people to gain access to

detailed information about the topic of medicine sharing. The posters will remain at Meals on

Wheels on display. Hundreds of people attend this feeding scheme, so the information will be widely

distributed.

Disadvantages were the printing costs which restricted the number of posters to two. Mass

production would have increased the information distribution. The posters may have contained too

much content which can deter readers.

Radio

Radio is mass media and can reach a large number of people. In 1998, approximately 72% of South

Africans used radio 20.Radio is also an inexpensive medium. This makes radio a good choice to deliver

health promotion information due to wide coverage and cheap costs.

Evaluation of the radio talk show

An interactive talk show was held between 10 and 11 am on Wednesday 22nd March on Radio

Zibonele FM 98.2, a radio station that covers the whole of Khayelitsha and is often involved in health

related issues. People were able to call in and get their concerns and questions, regarding sharing

medicine, addressed. The radio presentation was also valuable to understand the beliefs and

attitudes of the community. The radio presentation was very successful because; it reached a wide

audience, had audience interaction, it was inexpensive and was allocated a substantial time slot.

The radio talk show was limited because the allotted time slot was in the late morning when many

people are at work. Superficial messages were given due to the time constraints.

There was only an audio component to the presentation; messages are most effective when an

audio and visual component are used together. The radio talk show is once off, so the sustainability

of this aspect of the campaign is limited.

Dramatization

Dramatizations are effective ways to provide information as they are thought provoking and

stimulate debate. They can simultaneously entertain and educate. Participants can relate and

develop emotional responses to the characters and this may make it easier to adopt new

behaviours20.

Evaluation of the dramatization

The dramatization occurred at Meals on Wheels while people waited for their food. The

dramatization used actors and illustrated the dangers of sharing medication.

The short dramatization was well received. It was funny and informative. It worked well because the

information was relatable and understandable. It was inexpensive and time efficient.

The limitations of the dramatization was that the information was superficial. The dramatization

was once off and not sustainable. The dramatization was recorded, and may be distributed via a

webpage for further education use.

Role of advocacy

Advocating for people at an individual level, involves providing clear instructions about the

consumption of medication. Therefore, individuals who lack health literacy should be relayed

information at a level catered for them.

Community level

According to the stakeholder, individuals within the community share their medication. By

investigating why this occurs, clearly defined outcomes can be established1. For example, many

people don’t go the clinic because they are discouraged by the attitude received from health

workers.

The project aimed to address this by medical students going into the community and offering

screening services. The attitudes conveyed by the students, provided reassurance that affordable,

appropriate and acceptable care can be achieved by all health care workers.

The use of the local radio station advocated that more health education programs on self-

management for community members should occur on a regular basis.

Lobbying 22 consisted of the community’s role models meeting with the 4th year medical students in

order to make influential decisions. This facilitated the co-ordination of events such as health

promotion, where issues regarding the sharing of medication were addressed.

A forum1 took place, which encouraged the community members not to share their medication. This

is because it enabled them to communicate their concerns as to why they don’t attend the clinic,

thus prompting members to assist one another.

National level

Advocating for the availability of medication at all health facilities as well as better health care

access. In addition, providing an opportunity for the health workers to advocate for policy change

regarding the distribution of medication by the pharmacy without a prescription. This will promote

health by preventing the health consequences associated with the consumption of medication for a

disease, which hasn’t been confirmed by a doctor 23.

Stakeholder involvement

The experience with the stakeholder was not as valuable as hoped. Three meeting slots were

allocated, but only two were used and instead there was communication via email. The first meeting

wasn’t informative and there was little information to progress in creating the intervention. In the

second meeting, there was an attempt to clarify exactly what was expected. Some information was

provided, but a clear picture of the task and requirements was still lacking. In hindsight, the concerns

of the group have expressed the concerns differently and reached out to the stakeholder. This could

have resulted in a better work process. Overall, there was good collaboration with the stakeholder

to achieve the health promotion goal.

Reflections

There is great pride in the effort of the members and contribution to the community. Initially, it was

difficult to fully understand the topic, but with further guidance, the issues became clear. It was

difficult when visiting Meals on Wheels and witnessing the extreme socioeconomic challenges

specifically food insecurity. The project as whole was challenging especially working as a group with

time and budget constraints. In hindsight, the importance of good time management, open

communication and organization is evident. When preparing for the intervention, the language

barrier was an issue and it was initially decided to provide all information in English. After reflecting,

it was decided to provide the information in isiXhosa for the benefit of the participants. Overall, the

project was of great value and provided a good exposure to the harsh realities of a low SES

community. It gave the opportunity to try provide something of benefit to the community. The help

of the group facilitator, Mrs Xapa, is greatly appreciated who without, the interventions would not

have been possible.

Health rights and ethical principles

Health Rights

All health rights stem from the Bill of Rights in Chapter 2 of the 1996 Constitution of the Republic of

South Africa. It states, “Everyone has the right to have access to health care services, including

reproductive health care “ 24.

The interventions featured aspects of the Patients' Rights Charter25. Health information in the

participant’s language of choice was addressed through an intervention in isiXhosa. Information

regarding illness, treatment and the costs involved, was addressed by providing specific disease

related health information and a brief outline of treatment.

Autonomy

The setting of the intervention did not allow for full autonomy. Participants viewed the health

promotion activity while waiting for their food and had little choice in participation. While the

student group were allocate this time, autonomy was still breeched.

Informed consent was ensured by explaining the content and reason for the health promotion

before the activity. It was also ensured during screening via pre and post-test counselling.

Participants were free to withdraw from the screening at any time.

The participants were provided fresh fruit. Withdrawing from the presentation or screening did not

exclude them from partaking in the fruit.

Beneficence

The benefit of participating in the health promotion presentation was gaining knowledge and

improving the health literacy of the participant. The benefit of participating in the screening process

was knowing the result of the screening test and receiving a referral letter if needed.

Non maleficence

The risk to the participants was discomfort during the screening process, and potential psychological

harm from the screening result. This was minimized through pre and post-test counselling.

Justice

Unfortunately participants were not equitably selected for health promotion. All participants were

unfairly coerced into attending as leaving could result in not receiving a meal. There was however

distributive justice as those taking the burden of the research received the benefits in the form of

knowledge.

Conclusion and recommendations

Conclusion

Engaging with the community showed that the sharing of medication was not only a result of low

health literacy, but also factors such as poor access to health care services due to the heavy burden

of health services. The attitude of health workers also contributed to the fact that some patients do

not return for their appointments as well as the attitude affected the health care seeking behavior of

the people within the community. The low levels of socioeconomic status also contributed to the

people within the community not being able to access health care services especially those who had

to travel to certain clinics or hospitals.

Recommendations

It is important to treat each patient according to their socioeconomic context.

There must be provision of manageable information for patients at the level of their understanding

to prevent misunderstandings, as well as to make patients understand what medication they have in

their possession and its dangers.

Sustain the intervention, and distribute the dramatization and radio recording on social media.

Allow the posters to remain at Meals on Wheels and provide posters for community health clinics.

Educate health workers on the importance of health literacy and ensuring that they continue

informing patients on the risks of chronic medication sharing.

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