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The Impact of Health Literacy on Pharmacy
Practice
Sandra Salverson, PharmD, BCPS
OSF Saint Francis Medical CenterPeoria, Illinois
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Objectives
Compare and contrast health literacy, low literacy, and illiteracy
Describe the health-related consequences of inadequate health literacy
Identify three patient populations at risk for medication misadventures due to low health literacy or low literacy levels
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Objectives
Devise a patient education program that includes resources other than written information
Use the three questions from either the Ask-Me-3 campaign or the Indian Health Service Patient Counseling technique during a patient interaction to ensure patient understanding of medication regimens
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“ I can’t pronounce the names of my pills. I ask for them by their shape, size, and color”
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Definitions
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Literacy Definitions
Literacy: The ability to read and speak English
Functional Literacy: The ability to use reading, writing, and computation skills…in everyday life situations…on the job…in society
(National Literacy Act 1991)
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Health Literacy
The ability to read, understand, and act on health information and services to make appropriate health decisions. (Healthy People 2010 and IOM 2004)
Pill bottles Appointment slips Informed consents Discharge instructions Health education
materials Insurance
applications
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National Adult Literacy Survey (1993)
0
10
20
30
40
Percentage of Population in Level
1 2 3 4 5NALS Levels
Literacy Levels for Total Population
~50% of all U.S. adults read in the lowest two levels
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Illinois Literacy Rates
20% in Level 1 (at or below 5th grade level) 44% in Level 1 and 2 (at or below 8th
grade level)
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Pharmacist and Health Literacy Myth #1
I practice in the “affluent” and “educated” part of town – all my patients can read and do math.
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The Problem
Literate ≠ Health Literate
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Historic Health Information Model
Physician or health care providers have all the answers
Patients follow the directions
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Model Influences
Managed care Insurance dictums Medical breakthroughs Volumes of treatment options
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Participatory Health Care
Consumers are more responsible for their own health
Physician – patient partnership
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Patient Perspective
~80% of the population say health literacy is a serious issue
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Low Health Literacy Impacts a Patient’s Ability to Fully Engage in the Healthcare System
The Largest Study Conducted to Date on Health Literacy Found That…
Source: Williams MV, Parker RM, Baker DW, et al. Inadequate Functional Health Literacy Among Patients at Two Public Hospitals. JAMA 1995 Dec 6; 274(21):1,677–82
33% Were unable to read basic health care materials
42% Could not comprehend directions for taking medication on an empty stomach
26% Were unable to understand information on an appointment slip
43% Did not understand the rights and responsibilities section of a Medicaid application
60% Did not understand a standard informed consent
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Limited health literacy is not restricted to adults with limited overall literacy
Most health education materials are also “above the heads” of average readers
When context is unfamiliar, most of us are confused
Many of us have low health literacy at times
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My husband, my premature son and Synagis
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Who is at highest risk?
Seniors over age 65 Those living in poverty Minority populations Immigrant populations People with chronic mental and/or physical
health conditions
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Pharmacy and Health Literacy
52% of patients say that prescription information and instructions are hard to read and understand
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At-Risk Patients Pharmacy Experiences
“I never ask questions when I don’t get it. I don’t feel like I have the right to question the doctors”.
“I can’t pronounce the names of my pills. I ask for them by their shape, size, and color”.
…Take the capsules twice a day. “The label does not say when to take the capsules.
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Unfamiliar Health Care Terms
“orally” “apply locally” “hypertension” Cancer terms such as “screening”, “lesion”,
“mammogram”, “polyp”, “digital rectal examination”
Consent terms such as “placebo”, “randomly”, “efficacy”, “Institutional Review Board”
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Importance of Print Materials in Healthcare Research: Patients remember only 40-
50% of what a doctor says in an office visit Use of jargon: In one study, about 80% of
patients self-reported “no” or “little” understanding of doctor’s jargon
Understandable print resources can be critical to supporting people in their journey toward vibrant heath
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Health-literacy Gap
Average reading level of our materials is grade 10 to 13
Best reading level for at-risk populations is grade 4 to 6
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Impact of the Gap
Decreased patient satisfactionDon’t get our messagesDon’t follow our recommendationsWill not achieve desired health outcomeWe are trying to maintain “power”Lost trust and confidenceLess likely to return
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The Health Literacy Challenge
Is the information we provide useful? Is it clear and readable to our patients? Do printed materials support our mission
of pharmaceutical care? Are we using our resources wisely in the
print and web materials we produce and provide?
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Consequences
Misunderstood diagnoses Misunderstood directions for
administration of drugs Misunderstood self-care instructions
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Lack of Knowledge and Decreased Comprehension Diabetes Heart Failure Hypertension HIV
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Lack of Understanding and Use of Preventive Services Mammograms Pregnancy Vaccines
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Poorer Compliance Rates
Heart failure HIV
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Pharmacy Myth #2
I practice in a hospital pharmacy. I cannot control if patients do not understand prescription information. This problem does not impact my practice.
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Increased Hospitalization
Patients with inadequate health literacy are twice as likely to be hospitalized
Potential impactMedication reconciliationAdverse drug eventsNon-complianceDrug-drug interactions
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Increased Health Care Costs
$30 - $73 billion more in health care costs More physician visits Higher Medicaid/Medicare charges
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Increased Legal Risks
Lack of attention to health literacy could become a corporate negligence issue
In the future, providers may be negligent if problems related to health literacy were not addressed
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Accreditation Issues
JCAHO“The patient receives education and training
specific to the patient’s abilities…”Scoring includes evaluating whether
education is presented in a manner understandable to the patient
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Creating Solutions
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Improve Patient Education Materials Increase Use of Non-written Information Ensure Patient Understanding Promote Health Literacy
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Pharmacist and Health LiteracyMyth #3
I am only a staff pharmacist. I cannot change the material I use to advise patients.
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Quality of On-line Drug Information
Research shows on-line patient drug information varies in coverage and quality
Health-care professionals should be able to discern good quality
Consumers often cannot
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Do you, as a health-care professional have the capability of identifying quality on-line or printed patient health information?
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FDA Guidelines for Pharmaceutical Manufacturers Required
Disclosure of major risks
Side effects Contraindications Effectiveness
Optional Success rate Duration of treatment Alternative treatments
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What do people want to know?
What is the medication for? What does the medication do? How to take the medication? What are the side-effects?
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The Saint Francis Experience
Re-design of Patient and Family Education CommitteeMultidisciplinary commitment to develop,
implement, and disseminate appropriate education materials
Expand methods of delivery and presentation
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Quality of Education Materials
Meet patients’ educational needs and literacy level Need-to-know information essential to the plan of care Based on the adult learning theory Plain language Clear and inviting layout Employ several learning methods
Printed materials, interactive tutorials, and return demonstrations
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Goal for Patient Written Drug Information Evaluate and recommend one patient drug
information education resource for OSF-Saint Francis Medical Center
Resource would be available on-line and readily accessible
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Evaluation Criteria
Patient Usability Health Professional Usability Currency Content
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Patient Usability Comparison
0
10
20
30
40
50
60
70
80
90
100
Per
cen
t o
f T
ota
l Po
ints
Ava
ilab
le
Vendors Evaluated
80% Acceptable Threshhold
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Lexi-online
What is this medicine used for? This medicine is used to prevent or control
seizures. This medicine is used to treat migraine
headaches. This medicine is used to treat trigeminal neuralgia.
How does it work? Phenytoin calms the brain.
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www.safemedications.com
Why is this medication prescribed?
Phenytoin is used to treat various types of convulsions and seizures. Phenytoin acts on the
brain and nervous system in the treatment of epilepsy.
This medication is sometimes prescribed for other uses; ask your doctor or pharmacist for more
information.
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Target’s New Prescription Label
Target turns old pill bottle design on its head
Company hopes new containerwill grab customers'
Associated Press
Updated: 12:36 p.m. ET April 26, 2005
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Non-written Information
Verbal communicationOpen-ended questionsShow and Tell Questions
Visual illustrationsPicture labelsColor bands
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Finding a Solution
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Ask Me 3 – Creates Shared Responsibility for Clear Health Communication
Patient Provider
De-stigmatize andReduce Embarrassmentof Low Health Literacy
RecognizePatient Coping Mechanisms
Provides a consistent approach to patient-provider dialogue Allows patients to get information they need to manage their health Time-efficient for providers to reinforce healthcare instructions
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What Is Ask Me 3• Promotes three simple, but essential, questions
and answers for every healthcare interaction:
Why Is It Important for Me
to Do This?
Context
What Do I Need to Do?
Treatment
What Is My Main Problem?
Diagnosis
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Indian Health Service Technique• Promotes three simple, but essential, questions
and answers for every Pharmacy interaction:
What should you expect from this
medication?
How do you take the medication?
What is the medication
for?
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Clear Health Communication – We Can All Be a Part of the Solution
• Even if you are not in a position to directly answer the three questions, keep clear health communication in mind and in your dialogue when communicating with patients
• Many people have trouble understanding medical terms. Often, these terms are better understood when explained with common words, an example or visual interpretation
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Clear Health Communication in Action
Benign Harmless
Chronic Happens again and again; does not end
Cardiac Heart
Edema Swelling; build up of fluid
Fatigue Tired
Screening Test
Intake What you eat or drink
Generic Not a brand name
Adverse events Side effects
Consider Using This One Instead
Instead of Using This Word
Start by Decreasing the Use of Medical Jargon
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Pharmacist-Health Literacy Myth #4 If I ask my patients to ask more questions
it will increase the length of time I need to spend with them. I cannot afford to spend more time with each patient.
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Ensure Patient Understanding
“Just to make sure that I did not forget to tell you anything important, will you go over how you are going to use the medication”
Demonstrate Filling an insulin syringe Giving an enoxaparin injection Using an inhaler Filling a medication box
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Pharmacists Impact on Health Literacy CHF
Multi-disciplinary health approachOngoing study
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Promote Health Literacy
AMA Initiatives Acknowledge low literacy is a barrier Increase awareness in the health care community Train clinicians in effective communication skills for
patients with limited literacy Include health related questions on NALS 2002 Research
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Promote Health Literacy
Healthy People 2010 Objective “improve the health
literacy of persons with inadequate or marginal literacy skills”
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General Considerations
Create a shame-free environment and offer assistance when needed
Personalize the message Open relationships Invite family members or friends to
participate in patient visits
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General Considerations
Use simple and clear language Reinforce and repeat information often Link information to previous knowledge Tailor the information to the individual by
giving examples and explaining the relevance
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Pharmacists Promoting Health Literacy
Ohio Patient Safety InstituteMedication Safety Brochure
Pictures and graphics Circulated 65,000 brochures throughout Ohio
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Enter a partnership with your patients.
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Health Literacy
Patients are more involved with treatment choices
Patients are more informed regarding their disease
Patients are more invested in their health care
BETTER HEALTH CARE RESULTS!!
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Knowledge Is Power!
As your body grows bigger / Your mind will flower It's great to learn / 'Cause knowledge is power! It's Schoolhouse Rocky / That chip off the block of your favorite schoolhouse / Schoolhouse Rock