Monday, October 8, 2007

Week 7: Health Literacy

Post comments here! Also, remember to post in your personal blog thoughts about Module 2. This week is the start of Module 3: Media, Messages, and Positioning.

26 comments:

Ellainne said...

Health literacy was an interesting concept today. I never really thought about how health literacy really affects the public's opinion about receiving proper health information. As MPH students we've grown accustomed to hearing terms such as "mammograms, smoking cessation programs, or hypertension" when in actuality, there are people out there who have never heard or do not know what those phrases mean. What they may be more familiar with are x-rays of the breasts, stop smoking programs, or high blood pressure. A lot of computer companies want people to purchase their electronic products so they try to create "user friendly" programs, which allows the not so experienced computer user to successful execute a computer program. As Health professionals, we can try and incorporate that concept into our programs making them more "reader friendly"; therefore, getting our messages across in the most simple yet effective way.
As for the SMOG/FOG program, that was fun. Although our group tried to make our message as simple as possible to reach the 8th grade level, we ended up using language for 10th graders. Also, it's amazing how rearranging and replacing a few words can totally change the entire structure and reading ability of our message. I think the SMOG tool is a great way to figure out whether our health messages are too complicated to promote and will help to focus on certain groups that may not have a high sense of health literacy.

Crystal said...

Hello everyone! Man, wasn't class a little depressing today? I had no idea that so many people were illiterate and had trouble understanding things. I feel very fortunate to be receiving an education, and be able to "maneuver" myself within "today's economic environment". Being illiterate really does make people vulnerable to hardships. All of us being in public health really do have a responsibility to try to ensure that everyone understands our messages, so that everyone has an equal opportunity at being helped. Perhaps the scenario that was most interesting to me in the video was the woman trying to buy throat drops for her diabetic husband, and listed on the back of the box was " glucose, fructose..." - honestly, how is everyone supposed to know that glucose or fructose is sugar?
As a side note: I do some shadowing at a community clinic, and just recently someone came in that had been to the dentist, filled out a questionnaire in the lobby, and then was referred to the doctor that I shadow. They didn't understand the questionnaire and had marked that they have had medical complications in the past that would not allow them to have dental surgery. However, when they came to the doctor, and the doctor asked why they had marked "yes" to certain questions, they had no idea why. They said they had misunderstood. The doctor then signed a paper to approve the patient for the surgery and they were on their way.
As for the lab today, I thought it was a lot of fun! Our group found it kinda hard to write at 8th grade level (wow - we must be super smart =) ) So we wrote a "complicated" version first and then simplified, since we couldn't do the 8th grade stuff off the tops of our heads.
Well, thats all for now. Hope everyone is having a good start to their week!

Ellainne said...

Btw, don't forget to read about the Entertainment - Public Health Summit on my blog. It fits right into our discussion about the media and messages.

http://publichealth411.blogspot.com/

MariaF said...

It really is scary when we discussed in class how many adults in the United States are illiterate. Health literacy is a big patient safety issue for people with multiple health and medications to take. In class, there was one example in the video of a lady that did not understand the instructions of “take your medication twice daily”. She interpreted it as taking two of her pills in the morning. This confusing and lack of understanding can harm people. Medications to help control high blood pressure, diabetes and pain can help people manage a chronic condition, but if taken the wrong way can cause more harm to the body that help it.
As we’ve been practicing for the last few weeks, it is important to actively listen to people. It is important to ask open-ended questions, ask for patients’ opinions and to paraphrase so that we can ensure that patients or our target audience understand our message and instructions. Another important part of health literacy is the stigma and embarrassment that accompanies people that have literacy problem and like Dr. Engelberg stated in class it’s important that as public health educators/health promoters we recognize and are aware of this issue. It’s really dangerous health wise if an individual does not ask questions or clarifications about a medication prescription or health care procedures.
The lab portion of class was fun! The SMOG/FOG tool we used was a great way of finding out if our message is clear and easily understood by our audience. There are just too many fancy words out there...it seems that communication is becoming more less effective because we just don't use clear and simple words anymore. Believe me, where I work, there are just way too many medical jargon. There too many times when I have to get out a medical dictionary just to make a word clear to me before actually talking to my patients. Come on now how many people have heard of Esophagogastroduodenoscopy (EGD, stomach cancer screening) and Colonoscopy (colon cancer screening). It’s like the war of the words, it just never ends!

Danette F. said...

One of the topics in class was health literacy. This topic brought me back to my cultural competency days. After I finished undergrad I worked for a community health center on a project to increase cultural competency amongst physicians and staff. A large portion of patients were Hmong or Latino immigrants and there was a huge cultural/language barrier. The Hmong population were more challenging to work with because there were not many professionals/staff that spoke the language and their cultural beliefs were so different from westernized medicine. Some of the new Hmong immigrants were diagnosed with TB and were required to take medications for treatment. However, this was difficult for them to understand because in their country there is no doctor. They believe in a Shaman, which is a well respected person from the community that has spiritual powers to cross to the spiritual world. If a family member becomes sick or depressed they are sent to a shaman for help. Animals are sacrificed and the Shaman goes into a special trance state to cross to the spiritual world to ask the ancestors for advice or direction. So taking pills at certain times for a certain amount of days or months was totally unheard of. Physicians and healthcare staff really struggled to keep this population healthy because of this cultural misunderstanding. To make a long story short, physicians and the Hmong Shaman work together to treat Hmong patients. Some gaps still exist, but this project help fill a very important space.

I recognize that health literacy is a big problem in healthcare. I've come across so many patients, friends, and family members that just don't know what is going on. I find that many people don't know how to ASK...WHAT, WHEN, WHY? For example, my little sister who is in her early twenties living by herself in LA had a minor operation. My family lives about 6 hours north, so i'm the closest family member distance wise and of coarse the health expert. My mom was really worried about her so I took a day off to help her out on the day of her discharge. When I arrived at the Kaiser Hospital (oh, by the way I HATE HMO'S and KAISER...if you have this insurance I feel for you...these companies are money making heartless...bleep, bleep...you get the point!) they hadn't told my sister when to take her meds or when she needed to follow-up with a doctor. Nothing! The nurse just said...oh if you want me to call the doctor I can. Being the assertive woman I am, I said "YES get the doctor on the phone". I had my sister ask all the questions that I could think of and told her...you need to ASK. It's soooo sad! I mean, my sister is a smart, independent woman who speaks English fluently and luckly has a HEALTH EXPERT 4 A SISTER....but it made me think....what happens to people who don't speak up....who don't know English...who don't have a health expert in the family....who are illiterate???? How many new immigrants who can not speak English well and can't read are going to say to that nurse "oh yah, get the doctor on the phone, because I have a list of questions that he or she hasn't answered yet". That doesn't happen....they fall down the cracks and don't get the healthcare they need! Gosh...I could go on with this topic! Goodnight!:-).

Anonymous said...

Aside from being somewhat bitter about finishing the spring midterm, I was glad to see the questions remained the same.

I agree about the overall depressing nature of illiterate america. The women who said her pills were to be taken twice a day so she took two at once!! That could kill you. Messages need to be crafted that target that women. at her level. With pictures.

Jamie said...
This comment has been removed by the author.
Jamie said...

This week's class was by far my favorite class of the semester! I loved "In Plain Language," and was amazed at the number of Americans who do not understand health information. I had no idea that ~ 50% of Americans have low literacy skills, and the video definitely made me appreciate my education. The personal stories told by students from the learning center were fascinating, and I couldn't help but want to help them. The video was extremely interesting, but very sad at the same time.

"In Plain Language" also touched on the need for health care professionals to use language that can be understood by patients. Many times clinicians forget that not everyone has had the same schooling, and that the vocabulary they use might be confusing or misunderstood. This reminded me of a conversation I had with my neighbor-- a pretty intelligent guy might I add. He asked me what my thesis topic was and I explained that I was looking at house rules in relation to TV viewing while eating meals and its association with child BMI. He gave me a confused look and asked what BMI meant. ‘What? Who doesn't know what BMI is?’ is what I thought. "Body Mass Index. Duh." is what I said. I then realized, as a econ major, my neighbor doesn't talk about promoting healthy lifestyles, behavior change, BMI, etc. etc. on a daily basis. When he still didn't understand Body Mass Index, I simplified it by using "plain language," and said, "basically body fat." Then he got it.

As far as lab goes, I loved SMOG, and was very surprised at how much enjoyment I got from a website that determines the readability level of written materia!

It's the end of Module 2-- Know Your Target Audiences-- and my top three learnings were the importance of segmentation to categorize and understand your target audience, the effects of low literacy on health, and the drastic need to improve health literacy in the United States. I thought Rocio's presentation on hypertension was amazing, and it gave me a much better understanding of what we should be doing for our group projects. I enjoyed reading "Is There a Hard-To-Reach Audience?" and thought Dervin's "alternative conceptualizations" to preconceptions of "hard-to-reach" individuals were very interesting. As far as designing health campaigns, I learned that effective communication should be viewed as an exchange between participants, and that engaging members of your target audience is necessary to clearly understand them. I also thoroughly enjoyed VALS, PRIZM NE, and SMOG-- all of which I am sure I will continue to use!

slinke21 said...

Wow, health illiteracy is a HUGE problem! The statistics were staggering - around 50% of the population has inadequate functional literacy. How scary and how sad! No wonder so many people end up with complications due to failure to comply with medications properly! Actually, I'm surprised that more people are not in the emergency room for such things after seeing that! The part about filling out forms without being about to read them was especially scary. Perhaps asking every single person who reports to a clinic for the first time if he/she can read and understand medical literature would be useful. Maybe not being able to read well or understand medical terminology would not be so stigmatizing if the person at the desk asked in a non-threatening way and normalized the inability to do so. Very trick, though...
Regarding what Danette wrote about in her blog, I have not personally interacted with such populations, but in my Cultural Psychology class last year we studied the Hmong culture's different view of illness, medicine, and healing. Also, I took a course called Religion, Health, and Healing as an undergrad and learned a lot about Shamans and other healers. While these different views do not have anything to do with literacy in the strictest sense (i.e., written word or math), they definitely affect the beholders' understanding of our Western health/medical system and, in effect, the part that they will play in their healthcare. The debate is whether to meet them where they are or to try to force our views of health and illness on them.
Anyway, regardless of all of these other cultural issues, we should definitely strive to make our language as simple and understandable as possible.

Josie said...

Health Literacy, all I have to say is I hope I dont accidently sign up for a hysterectomy!!! On a daily basis at work I am repeatedly answering quesitons about the complexity or awkward wording of two required patient forms. One is the HIPPA form, most people do not take the time to read the hippa policy and just sign away, the next is the Family Pact Form for state funding to pay for birth conrtol. THis form can potentially save the patient hundreds of dollars. THe form looks like it was created in 1900 and is soooo not user friendly. DUe to this patients opt to decline the funding instead of filling out the form. This form doesnt have a lot of medical jargon, but it looks intimidating and time consuming. WOuldnt it make more sence to have the forms SMOGed or FOGed and take the clutter down a notch, it would certainly make my job a little easier and the decrease the frustration of the patient. Its slao interesting to me that well educated people often struggle with health infomation, so lets just make everything a little essier and SMOG down to an 8th grade level...

Amanda Miller said...

I never really thought about how much of an issue health literacy can be. I am the only person in my family who was fortunate to go to college and take numerous anatomy and physiology courses. Even this level of health knowledge is not enough to completely understand medical information.

I connected with the statements of the people on the video who explained what they do to "get by". I am very close with my aunts and uncles and it wasn't until I was about 17 years old that I found out that one of my uncles has a very low reading level. This is a man who has been in and out of hospitals numerous times for various reasons. I am sure that he didn't understand much of what he signed. How scary!

We often get so used to using upper level academic language that we forget that our main goal is to reach out to the public.

Lindsay said...

Health literacy is something I hadn’t really thought much about before, but now realize how important it is for us to put what we mean in plain language. A couple of the video's examples stood out to me. One was the lady trying to buy throat drops for her husband who had diabetes. She was reading the labels to make sure to get something without sugar. Because the label did not read “sugar” she assumed it was fine. However, it did read fructose and glucose, yet she didn’t realize that meant sugar.
Another example that sticks out to me was the lady who took both her pills in the morning opposed to one in the morning and one at night, but because she couldn't understand she was doing it wrong. These are examples of what happens to people when we don’t speak and write in plain language.
Something I learned about myself in this lab exercise is after we watched the video and looked at a PowerPoint presentation I realized I could barely remember anything that was on the slides, yet several different stories stuck out in my mind from the video. I guess different people have different learning styles, but for me stories stick better than facts. A personal example is that if I watch a movie based on Pearl Harbor or WWII events I am much more likely to learn than if I read a history book.

Juanita.Andrews66 said...

Yes, as we've learned and as many have already commented on with their own experiences, health literacy is definitely a problem. However, I think the medical community has already conquered one of the biggest obstacles to solving this problem, which is identifying that it is a problem. After watching the stories of those ppl who compromised their health due to low health literacy, all I could think of was that I'm blessed my reading comprehension of health related materials has never put me in that situation. And, honestly, like the video said, just being college educated doesn't necessarily mean health literacy; which is something we in public health must be careful of when tailoring campaigns to this or equivalent populations.
-------------o------------------
Another thing that I stood out for me was the definition of health literacy, which more or less is: obtaining, understanding, interpreting health related material. So, when working with unique populations, its important to not only to "dumb down" (what's a better term, I'm not sure I saw one in other blogs nor do I remember one from class) language , but make sure it is relevant to that pop.

Megan Koske said...

I have to agree with Maria about that lady who took both of her medications at the same time because she did not understand "take twice daily". That was a HUGE take-home message for me. I guess I really take that for granted as morning and evening and how dangerous this situation can be depending on the medication.

As for a personal story: After my father died in march his mother did not handle the news very well and she was briefly hospitalized because she had an anxiety attack and her heart beat out of rhythm. Anyway, since then she has been on what I would consider tons of medication some that she takes twice daily and others once a day and still others twice on one day but once on another. She literally did not understand what medication was for which ailment and was deciding not to take certain ones mistaking them for others. I have to go to her house and set up her medications weekly so that she takes the right ones at the right time. I also had to set an alarm for her so that she takes her medication at the right time of day. In addition she did not understand the directions of "eat a light lunch" or "take with food" and was getting upset stomach on top of everything else. My family has since given her a list of what is appropriate for "light lunch" and what foods to eat with her medication to help her sensitive stomach. But for me it was a lesson in what I take for granted and how easily someone who lives by him or herself can overtake, undertake or just not take the correct dose of medication.

As for the SMOG/FOG test I found it really helpful in our group when we wrote a complex message first and then converted it for a "reader friendly" version. It is truely amazing that I have been blessed with the oportunity for higher education.

cheerstohealth said...

Health literacy is something that I have always wanted to learn more about. Back in India when I was working in an non profit for HIV/AIDS my job included counseling people about medication adherence. The people who came to the center all had either low or no literacy levels and most of them couldn't read or had basic reading skills. Watching them struggle to understand not only the medication dosage but also why some medication s were taken at certain times was quite a disheartening experience. Finally we decided to take classes for them where we drew out each medication and also used images of the medication to help them sort through the entire gamut of medications. After this we actually noticed a difference and improvements in their adherence as they now knew what they were taking when and why. The SMOG tool seems like something I will definitely use in the future to help me plan anything for audiences from various literate levels.

The entire module 2 was fascinating and I have to say that I loved the whole bit on segmentation and how important it is. It makes me so much more comfortable planning a health communication campaign now that I can segment audiences and base my campaign on one segment rather than focusing on all and making a mess of it

Jennie N said...

I thought that the SMOG/FOG test was an interesting idea and a good tool. But what about words like "exercise", "physical activity", etc.? We use those words all of the time even though they have 3 syllables and would thus raise the reading level. I guess there's a balance. My group got it down to 6th grade reading level. Is that too low? Would people be offended? In the end, this lab can help us reach the low literacy group. But the situation seems more dire than that, so should we actually be focusing on more visual messages?

It was good to get a reality check and to get out of the ivory tower. My job doesn't always allow me direct access to the community so it's easy to forget about readability. As students, we have to separate classwork from work in the community. We are expected to work from a higher level of literacy in classes, so it's easy to let that spill over into health communication pieces for the community.

Anonymous said...

On Tuesday, my group had a meeting for our project at the County Public Health Services building and I can honestly say, as “educated” as we are, we did have a little trouble navigating the long hallways to find the Immunization Branch. It made me think about our talk on health literacy, I could see how the signs could be a little overwhelming and confusing since there are some many services in that building. I can also understand how that confusion could lead to frustration and make people less likely to seek services. Another point regarding health literacy, which we encountered from our meeting was over the terms Influenza vs. Flu. It’s important to realize that these two terms could mean two completely different things to different people. If a person is not familiar with the term Influenza, it could mean nothing to them at all and they could completely overlook the message we are trying to send.

Watching the video, “In Plain Language”, was difficult because it’s hard to accept that there are still so many people in our country that are illiterate. We often take advantage of the fact that we are able to read and comprehend, what we believe to be simple tasks like taking our medication properly. This is definitely an issue that health educators need to keep in mind when creating programs for the community.

The SMOG/FOG lab was fun, challenging, and educational. As health promoters, it’s easy to get caught up in our own knowledge; so it’s nice to have a tool that will help you make understandable and further reaching messages.

Shelbs said...

Howdy! It seems I am always one of the last ones to post for the week...hmm...Anyway, after almost each class, I come out wanting to take on a new profession--one week I wanted to interview people about their passion for motorcycles, and this week, I thought it would be pretty darn cool to go into teaching. But then I remembered my "fun" with tutoring a 3rd grader for a year using "hooked on phonics". Neither of us were really hooked on it. Nonetheless, I agree with many fellow students saying that they didn't realize health literacy was a problem. For me personally, I had never really thought of health literacy as being a subset of literacy. Now these past few days when I look at an ad, billboard or read an article of some sort, I try to mentally put it into the SMOG thingee and guess what level it would be. For our questions to ask of the Walking School Bus parents, I found my self wondering if they would know what "walkability" means---similar to Jamie D's braniac neighbor not knowing about BMI.

Yes, Laura, I think we should put our theses in and see what grade level comes up....do we really want to know?

As for Module II, it was really hammered home that in order to be effective we really must pick some group, narrow it down--we can't save the entire world in one campaign. And I still think PRIZM is pretty keen---I know what I'll be doing over Christmas break in Salt Lake City with the folks...the fun never ends in Utah!

Wish us luck tomorrow with our PTSO meeting! Hope all is going well with everyone's projects!

slinke21 said...

Today I came across this press release of a study's results and thought it really spoke to what we discussed in class regarding health literacy: http://news.yahoo.com/s/nm/20071011/hl_nm/medication_errors_dc;_ylt=ApkOZcRNhaQQnmWZjTxbuT8Q.3QA
I also read a meta-analysis for another class about non-compliance rates in patients, linking them to some demographic information, type of treatment, type of disease for which the treatment was prescribed, and method of assessing compliance. It revealed an average non-compliance rate of around 25% across the board, with highly varying rates depending largely on the factors listed above. Not surprisingly, people were more compliant with medications for short-term problems than chronic conditions and with medication treatments than behavioral changes (e.g., exercise, diet). Anyway, funny how these things came up in my life when we were studying them in this class!

Alicia said...

Well we are now done with module two and in the middle of the semester! It is amazing how fast the time goes by...and it's a little scary when you are working on your thesis! = ) I really enjoyed this part of the class. I thought it was great to find ways to reach your audience. As health communicators we always know the message we want to put out there but how do we know it is being recieved? It is great to have tools like PRIZM and VALS that we can use to try to figure out what kind of message our target audience will listen to.

More on my blog!

ldt said...

Literacy was the main topic this week.
We discussed and worked in groups to create simple messages to inform the general public on health issues. Rewording messages that seem simple to those in the health field is essential to getting information across to the public. When our group first tried to create a simple message about climate change, it proved too tricky to just sit down and write something simple… so we had to back up and write a complex version that we could then adapt! Using the SMOG tool to grade the writing samples was great, and I wish hospitals would use SMOG before they passed out information on anything. From medication info to interpreting the results from basic blood tests, they try to make things simple, but the wording can be confusing even for many with college degrees.

Such a basic concept: clearly explain what a person is getting into before sending them off to take care of themselves… I have always had to do that in any area of research I’ve worked, it’s called informed consent! Even though health care providers aren’t running experimental procedures, the informing process should still be the same. Sure, throw out the technical lingo, but watch the person’s reaction when you do that. When their eyes glaze over and they just starting nodding along, you can finish your thoughts, but then bring it back and paraphrase so they can understand. Never just hand someone a piece of paper with instructions and then assume they’ve got it! Most recently, working in a smoking cessation program, all of our information was written clearly on the medications people would be using, and we also sat down with them for ten to twenty minutes to make sure everything was clear. On every successive visit, our first question was if they had any questions! It gave people the opportunity to get their thoughts out right away before being bombarded with more facts and procedures.

It’s frustrating that our health care system is run as it is… the professionals don’t have time to talk to people and make sure everything is clear. Researchers are held to a high standard, which makes sense due to their funding and protocols, but health professionals should strive to reach that same standard. Taking the time to explain information to patients clearly also establishes a strong rapport which encourages patients to ask questions and discuss issues that they might normally be too shy or intimidated to talk about!

Ceci said...

It was interesting and sad to see how many people in America were illiterate! Then again, even intelligent people may not necessarily understand specifics about their own prescriptions or new drugs on the market. A lot of us just tend to do what the doctor tells us, right?

The SMOG exercise in class was fun. Apparently my group is pretty good at writing at an 8th grade level!

Michelle Plata said...

It seems there is an assumption in this discussion that health providers have the answers; that consumers need to have health information explained, and should follow the easy-to-read directions.

That is an inequitable and dysfunctional relationship.

Why learn to communicate in words the public understands if health educators do not respect the individual people that comprise "the public" as equal partners in a healing relationship? What if we instead assumed that consumers are the experts on their own bodies? And what if consumers felt empowered to challenge and question every provider?

Earlier this week I called an advice nurse becasue my baby was sick. She gave me "advice"...bad advice. Since when are white potatoes and regular pasta "complex carbohydrates"? And, contrary to her advice, I did not give my baby Crystal Lite. Sure dehydration will get him faster than cancer, but come on - Crystal Lite?!?! Aspartame, benzene...I won't drink the stuff so I'm sure not going to give it to my infant.

This is another reason why health literacy is important: it's not just so people will understand and follow health advice, it's also so they will understand when the messages are completely off-base and need to be questioned and/or ignored.

iris.rayngay said...

I’m officially in 17th grade. 12 years of primary education + 4 years of undergraduate + 1.5 years of graduate school = a whole lot of school! After being a student within the education for numerous years, I forget how natural it is to include “big” words into my written documents. Unfortunately, higher levels of literacy levels are not comprehended by most Americans.

Brochures, pamphlets, flyers are common health media resources distributed to the community. However, developers tend to assume everybody is able to comprehend medical terminology. Instead, it’s better to develop information materials at an eighth grade reading level.

Simpler is better! So, do it for America. It's time to break that addiction to sesquipedalians. :P hehe.

Jennie N said...

Comment from Laura S.
October 8, 2007 11:57 PM

Health Literacy
I have to agree with the health literacy video I saw today. When I think of health literacy, I think of educated people even being confused by pharmacy terms. Luckily, my dad works in the pharmacy department in Kaiser, so I learned about drugs and my family (mom side) consists of 86.9% medical doctors.

The video we saw today was really monotone, but the lady did raise her eyebrows during the video. I didn't like how the video was played. It seemed too... old. I like Dateline type of videos.

These are good videos on health literacy. These seem more up-to-date. I tried watching the video earlier (we watched in class), but the link didn't work for some odd reason. :P

Anyways, health literacy is honestly going to get worse... especially with the lower literacy rates in people in general going down. It's insane how the education system is at the moment. If people are having trouble with literacy in general, then how the heck will they be able to get through health literacy?

Now with the SMOG grading, that was fun.

http://www.literacytrust.org.uk/campaign/SMOG.html

It makes me wonder how I write in general as a person. I try to write as a professional and use "big words" heh heh. But in a way, it's difficult because you don't want to sound like you're trying too hard.

I would like to try to put my thesis in this. I wonder how it'd do. heh heh. That'd be sad if I were a 3rd grade writer. My boyfriend would sooo make fun of me. He's an amazing writer. :)

As for our project, we're so close to getting this stuff done. I need to do the lit review and get it done too. Sigh. WE CAN DO IT! GO FOOD! GO STAMPS!

EVERYONE - PUT YOUR THESIS IN THE SMOG PROGRAM!

For more... my blog

Jennie N said...

Comment from Laura S.
October 9, 2007 12:01 AM

You know what I was thinking... I worked in Mexico and with indigenous groups. The UABC med students prescribe medications, but I wonder what the indigenous groups are thinking. The medications given to them are for parasites and/or anemia. I wonder if they understand how often and when to give their children the medication. It's sad because these groups are difficult to really evaluate.