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Health Literacy in the Pharmacy

Practical Strategies to Improve Communication With Patients
Adam Carlisle MD
Kara L. Jacobson MPH
Lorenzo Di Francesco MD
Ruth M. Parker MD

INTRODUCTION

Poor health literacy, also known as low health literacy, is extremely prevalent and a major cause of the inability of patients to take medications properly. Health literacy is determined, in part, by the complexity of the health care delivery system—and the pharmacy serves as a critical component of that system, as it remains the last patient–provider interaction before patients begin taking their prescribed medications at home. This article provides an overview and a brief summary of how health literacy can be addressed at the pharmacy on both the individual and the system-wide level. Individual pharmacists can work to improve their patient–provider communication, and pharmacies should work to create a patient-centered system of medication delivery in order to increase both efficacy and safety.

WHAT IS HEALTH LITERACY?

According to the Institute of Medicine and the National Library of Medicine, health literacy is “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”1,2 Components of health literacy include patients’ ability to obtain health information and services, to process and understand health information, and to make appropriate decisions about their health care.3

Culture and society, education, and the way in which the health care system interacts with patients are all determinants of health literacy.3 Of vital importance to health care providers, health literacy is determined not only by the skills that patients possess but also by the complexity of the health care system and its demands on individuals (Figure 1).4 In this context, the pharmacy serves as a crucial part of this system.5,6 The pharmacy remains as the last face-to-face opportunity for patients to learn how to take a medication safely and effectively.

WHY IS HEALTH LITERACY IMPORTANT?

The problem of limited health literacy is well established.79 Poor health literacy is a “stronger predictor of a person’s health than age, income, employment status, education level, and race. Groups with the highest prevalence of chronic disease and the greatest need for health care have the least ability to read and comprehend the information needed to function as patients.”10 Limited health literacy is also associated with a large number of adverse health outcomes.1117

Healthy People 2010, a government report, was published in 2000; it provided objectives to improve the health of all Americans and included improved health literacy as Objective 11–2.18Healthy People 2020, published in 2010, also includes specific national goals for health literacy.19

The Patient Protection and Affordable Care Act of 2010, which became the law mandating health care reform, also mentions health literacy, specifically the goal of improving prescription drug labels to enhance patients’ ability to understand and to safely and effectively take medications.20 The Joint Commission has focused greater attention on health communication and has developed guidelines to enhance the readability of patient materials.21

HOW IS HEALTH LITERACY RELEVANT TO THE PHARMACY?

Understanding how to correctly take a prescribed medication is an issue at the intersection of health literacy and patient safety. Numerous studies over the previous 20 years have shown that many adults have difficulty understanding common instructions on how to take their medications.2125 In one study, 46% of 395 patients misinterpreted at least one instruction on prescription drug labels.25 Patients who are identified as having lower health literacy are at greater risk of misunderstanding medication instructions.26

Two principal reasons for this confusion are the unnecessary complexity and the great variability of the wording on the labels.27,28 Physicians are neither uniform nor consistent in how they write dosing instructions.29 Different pharmacies might also translate physician prescriptions in different ways.30 Two reports by the Institute of Medicine—Preventing Medication Errors in 2006 and Standardizing Medication Labels in 2008—mentioned the inadequate quality and the variability of drug labels to be a root cause of a great proportion of adverse drug events (AEs) and medication errors.1,23

As early as the 1970s, pharmacists have led programs in teaching patients about how to properly take medications.31 However, the American Society of Health-System Pharmacists (ASHP) raises the concern that according to its National Hospital Pharmacy surveys, very few patients receive medication education from pharmacists, and even fewer pharmacists inform all of their patients how to take their medications.32 Only a small number of studies have examined the role of the pharmacist in patient communication and education even though pharmacists are often viewed by patients as the most valuable33 or second-most reliable source of information about their medication.3436

Despite the barriers to clinical implementation, pharmacist counseling has been shown to improve patient knowledge, adherence, and correct use of medication.37 Patient–pharmacist counseling also leads to greater patient satisfaction with the pharmacist consultation.38

How Can We Improve the Pharmacy?

First, it is essential that we acknowledge the prevalence and implications of limited health literacy. Low health literacy can be predicted to be present, to a greater or lesser extent, in any given population,7,8 yet it is impossible to identify individuals with low health literacy as they walk through the pharmacy door. Second, we must understand the relationship between health literacy and errors in taking medications. With this in mind, patients should be screened for health literacy in the pharmacy; in addition, universal systematic measures should be instituted so that all patients leave the pharmacy knowing how to take their medications correctly.39

There are opportunities for improvement in the pharmacy on the individual pharmacist level as well as in the larger system. Changes on both fronts can facilitate a patient-centered system of medication education that is understandable, accessible, standardized, and easily navigable. Patients receive medication information from a multitude of fragmented and constantly changing sources.1 A successful system should make these sources complement, not oppose, each other, with the goal of reinforcing reliable and easy-to-understand content about the safe and effective use of medications.

The model represented in Figure 2 illustrates the role of the pharmacy in minimizing the demands and complexities in order to improve health literacy and health outcomes. In this article, we discuss two types of interventions specific to the pharmacy: face-to-face counseling and standardized labels.

Pharmacist Improvements

Individual pharmacists can improve their patients’ health literacy by implementing a three-step process, developed by Jacobson and colleagues:39

  • assessing the pharmacy for health literacy–friendliness
  • training the pharmacy staff in clear communication
  • introducing interventions to facilitate medication adherence, such as pill cards (Figure 3) and telephone reminder systems

Assessment

A pharmacy health literacy assessment is an important first step for quality improvement in organizations that serve individuals with limited health literacy.5 A pharmacy assessment:

  • raises pharmacy staff awareness of health literacy
  • detects barriers that may prevent individuals with limited literacy skills from accessing, comprehending, and taking advantage of the health information and services provided by the organization
  • identifies opportunities for improvement

To evaluate the health literacy–friendliness of a pharmacy, it may be helpful to access the pharmacy assessment tool on the Agency for Healthcare Research and Quality (AHRQ) Web site. Assessment consists of conducting a tour of the pharmacy using the Web site’s auditing tools and techniques, carrying out a survey of the staff to identify barriers and best practices, and convening patient focus groups to help provide an opportunity for patients to voice their concerns in the process. If time and resources are limited, the pharmacy staff should do as much of an assessment as feasible, with the goal of making the practice setting more health literacy–friendly.

The Web site for the AHRQ’s Pharmacy Health Literacy Center is www.ahrq.gov/pharmhealthlit/ (Is Our Pharmacy Meeting Patients’ Needs? A Pharmacy Health Literacy Assessment Tool User’s Guide).

Communication Training

The pharmacist is often the patient’s last opportunity for verbal and printed instructions on how to take medications properly. This role is particularly important, because patients with low health literacy often comprehend more when directions are explained verbally.40 Despite the prevalence of patients with poor health literacy,2125 as well as the data linking health literacy to adherence41 and outcomes,1217 few pharmacies have attempted to assist patients with limited health literacy skills.42 Pharmacists can improve patients’ ability to take medications properly by learning how to communicate more effectively (Table 1).

Speaking slowly and remembering not to use medical jargon is important, but many providers tend to change their conversational tone. Doctors have a tendency to speak in a louder voice, as if addressing a child; this can be perceived as insulting to some patients and should be avoided, because low health literacy can be associated with a palpable stigma.43 This change in tone can have detrimental effects; it can offend patients or, more often, may cause them to feign a false understanding, thus contributing to further misunderstanding.

Next, pharmacists should specifically ask patients for any questions they might have about their prescriptions. “What questions do you have?” is more effective phrasing than “Do you have any questions?”

Pharmacists should keep their message simple and should focus on what is pertinent for the patient to know in order to take the drug correctly.

Finally, using the “teach-back” method is crucially important. In one study, patients were much more likely to take their medications correctly if they could show a health care provider which tablets they would take instead of simply repeating instructions that the provider spoke moments before.39 Effective teach-back comprises a four-step process (Figure 4:44)

  • Clinicians should place the burden of communication and understanding back on their own shoulders. For example, “I have covered a lot of information about high cholesterol today, and I want to make sure I did a good job of explaining this.”
  • The session should be focused on a specific behavior. For example, “Can you tell me when and how you will take this medicine?”
  • The patient should be corrected as needed.
  • Reassessment serves as a quality control and is the only way to determine whether the patient understands the information; this is the most important and most often overlooked step. If the patient does not understand, the facts should be explained again in a different manner. Clinicians should continue to explain until both they and the patient agree that the information has been understood.
  • Instructions regarding how patients should take their medications are vitally important. Patients’ recall and understanding of these messages are predictive of medication adherence, which leads to increased medication safety and efficacy.41

    Developing Interventions

    In addition to the strategies designed to improve oral communication, the use of patient education tools, such as pill cards and automated prescription reminder telephone calls, can be helpful for some patients with low health literacy.

    A pill card (see Figure 3, page 578) is a simple, direct, and effective way to show patients which medications they should take and when.45 Step-by-step instructions for how to make pill cards, including the format and suggested graphics, can be found at the AHRQ’s Web site (www.ahrq.gov/pharmhealthlit/.29 An automated telephone reminder system calls patients to remind them to refill their prescriptions and allows patients to order their refills by phone.

    The successful patient-centered pharmacy should address awareness of limited heath literacy; detect barriers that prevent patients from assessing, comprehending and using health information correctly; and identify opportunities for improvement.39 More information to aid pharmacies in assessing and meeting these goals can be found at the AHRQ Web site. The main goal is to ensure that all patients who leave the pharmacy understand how to take their medications. Actively educating patients with a pill card makes it easier for the pharmacist conducting the counseling.46

    Systematic Pharmacy Improvements

    System changes can take place on many levels. One communication method of particular importance involves prescription medication labels, which represent the very last line of instruction that either enables patients to take their medications properly or causes further confusion.47 Long after patients have left the hospital, doctor’s office, or pharmacy and moments before patients actually self-administer a medication, they still have the prescription label to guide them as to how to take the drug safely and effectively.

    Electronically generated prescriptions have also been shown to be both easier to understand and less likely to lead to patient errors than traditional handwritten prescriptions. If all pharmacy systems were standardized to use uniform electronic prescription entry, from physician to pharmacist to patient, a significant number of medication errors could be prevented. The system would also be able to ensure that patients with low health literacy would receive clearly phrased and easy-to-understand written instructions.29

    Limited health literacy and complex medication labeling instructions can lead to errors not only in the quantity of medications taken but also in the frequency of dosing. In a study regarding parents’ ability to give a medication to their children correctly, the type of measuring device included with the drug, the inscription on the device, and the instructions all played a large role in determining whether children received a correct dose.29 The percentage of parents who administered a drug accurately (within 20% of the recommended dose) was 30.5% when they used a cup with printed markings and 50.2% when the cup had etched markings. By contrast, more than 85% of the parents gave the correct dose with a dropper, a dosing spoon, or one of two different oral syringes.45 Both parents and their children would be well served if the markings on liquid measuring devices were standardized to a volume measurement that corresponded to that indicated on the label.48

    In one study, patient-centered instructions were more likely to be understood than standardized labels.49 Specific changes to the label included translation of physicians’ order-entry codes and instructions into simplified phrasing for lay-persons—the simplified language was most easily understood, as determined by survey results. For example, “take one pill by mouth once daily” became “take one pill at bedtime.”

    It is the responsibility of both pharmacies and pharmacists to be involved in advocating for a better system of medication labeling that is patient-centered and that offers information that is understandable, accessible, and easily implemented. Increased regulatory oversight could help to achieve this goal. Pharmacists should continue to be actively engaged in their key professional societies and to apply pressure to standardize and improve prescription drug labeling in an evidence-based and patient-centered manner. The U.S. Pharmacopeia (USP) regularly promotes standards for improved medication labels, reflecting formats that utilize lessons of health literacy and offering content that is patient-centered.5057 As these changes are more widely adopted, all pharmacies and pharmacists should work to implement prescription labels that correspond with the USP patient-centered medication guidelines.

    CONCLUSION

    Limited health literacy is quite prevalent in the U.S.79 Low health literacy has been shown to lead to both poor patient adherence41 and poor health outcomes.1217 Health literacy is influenced by multiple factors, including the complexity of the health care delivery system.4 The pharmacy is a critical part of that system,5,6 but generally speaking, pharmacists have not been communicating in a sufficiently consumer-friendly manner to address patients’ problems with comprehension. Forty-eight percent of patients misinterpret medication drug labels, and many take their medications improperly.2125 We can help patients by training individual pharmacists and by implementing system-wide changes. There are many established educational mechanisms available to improve the way in which we communicate with patients on a daily basis.39

    As health care providers, we can also change the way we write and interpret prescriptions, deliver information about pharmaceuticals, and compose prescription drug labels that have the potential to create a patient-centered system of care that will help patients take medications more safely and effectively. Pharmacists can and should play a critical role in advancing the health literacy of our nation.

    Figures and Table

    Health literacy framework. (From Parker RM.)

    Enhancing health literacy and outcomes. (Modified from Parker RM.)

    The pill card can be an excellent way to educate patients about their medications.

    The “teach-back” method is a four-step process. Proper teach-back applied between a pharmacist and a patient leads to improved adherence. (From Ley P41 and from Schillinger D, et al. Arch Intern Med 2003;163(1):83–90.44 Copyright © 2003, American Medical Association. All rights reserved.)

    Effective Verbal Communication

    What Pharmacists Can Do Every Day Examples
    Speak slowly When slowing down the pace of your speech, omit “nice-to-know” information.
    Focus on what the patient needs to know.
    Do not use medical jargon Instead of saying “hyperlipidemia,” say “high cholesterol. Cholesterol is how much fat you have in your blood.”
    Use an adult tone but simple, direct diction (i.e., “living-room” language) Instead of saying “Discontinue medication if associated with rapid fluctuations in blood pressure,” say “If the bottom number of your blood pressure is less than 45, stop taking this medicine.”
    Solicit questions effectively and consistently Instead of saying “Do you have any questions?” say “What questions do you have?”
    Limit the message to one to three main points Simple = effective
    Use a “teach-back” method Be certain to assess the patient’s understanding, such as saying, “Mr. Smith, can you show me how you would take this medication?”
    Author bio: 
    Dr. Carlisle is a Resident in the Department of Internal Medicine at Barnes–Jewish Hospital, Washington University School of Medicine, in St. Louis, Mo. Ms. Jacobson is a Senior Research Associate in the Rollins School of Public Health at Emory University in Atlanta, Ga. Dr. Di Francesco is Associate Professor of Medicine; Program Director, J. Willis Hurst Internal Medicine Residency Program; and Assistant Chief of Medicine, GMH, at Emory University School of Medicine. Dr. Parker is a Professor in the Department of Internal Medicine at Emory University.

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