The Impact of Health Literacy on Pharmacy

Practice

Sandra Salverson, PharmD, BCPS

OSF Saint Francis Medical CenterPeoria, Illinois

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

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

“ I can’t pronounce the names of my pills. I ask for them by their shape, size, and color”

Definitions

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)

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

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

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)

Pharmacist and Health Literacy Myth #1

I practice in the “affluent” and “educated” part of town – all my patients can read and do math.

The Problem

Literate ≠ Health Literate

Historic Health Information Model

Physician or health care providers have all the answers

Patients follow the directions

Model Influences

Managed care Insurance dictums Medical breakthroughs Volumes of treatment options

Participatory Health Care

Consumers are more responsible for their own health

Physician – patient partnership

Patient Perspective

~80% of the population say health literacy is a serious issue

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

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

My husband, my premature son and Synagis

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

Pharmacy and Health Literacy

52% of patients say that prescription information and instructions are hard to read and understand

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.

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”

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

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

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

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?

Consequences

Misunderstood diagnoses Misunderstood directions for

administration of drugs Misunderstood self-care instructions

Lack of Knowledge and Decreased Comprehension Diabetes Heart Failure Hypertension HIV

Lack of Understanding and Use of Preventive Services Mammograms Pregnancy Vaccines

Poorer Compliance Rates

Heart failure HIV

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.

Increased Hospitalization

Patients with inadequate health literacy are twice as likely to be hospitalized

Potential impactMedication reconciliationAdverse drug eventsNon-complianceDrug-drug interactions

Increased Health Care Costs

$30 - $73 billion more in health care costs More physician visits Higher Medicaid/Medicare charges

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

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

Creating Solutions

Improve Patient Education Materials Increase Use of Non-written Information Ensure Patient Understanding Promote Health Literacy

Pharmacist and Health LiteracyMyth #3

I am only a staff pharmacist. I cannot change the material I use to advise patients.

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

Do you, as a health-care professional have the capability of identifying quality on-line or printed patient health information?

FDA Guidelines for Pharmaceutical Manufacturers Required

Disclosure of major risks

Side effects Contraindications Effectiveness

Optional Success rate Duration of treatment Alternative treatments

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?

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

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

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

Evaluation Criteria

Patient Usability Health Professional Usability Currency Content

Patient Usability Comparison

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90

100

Per

cen

t o

f T

ota

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ints

Ava

ilab

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Vendors Evaluated

80% Acceptable Threshhold

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.

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.

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

Non-written Information

Verbal communicationOpen-ended questionsShow and Tell Questions

Visual illustrationsPicture labelsColor bands

Finding a Solution

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

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

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?

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

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

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.

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

Pharmacists Impact on Health Literacy CHF

Multi-disciplinary health approachOngoing study

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

Promote Health Literacy

Healthy People 2010 Objective “improve the health

literacy of persons with inadequate or marginal literacy skills”

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

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

Pharmacists Promoting Health Literacy

Ohio Patient Safety InstituteMedication Safety Brochure

Pictures and graphics Circulated 65,000 brochures throughout Ohio

Enter a partnership with your patients.

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!!

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