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Health Literacy in Pharmacy: Communication Strategies
Curricular Modules for Pharmacy Faculty

Content adapted from Kripalani and Jacobson (2007)

Slide 1

Overview

• Health Literacy in Pharmacy.
• Communication Strategies:
  • Recognizing Low Health Literacy.
  • Improving Communication.

Slide 2

Health literacy in pharmacy

Slide 3

Health Literacy: An Interaction

• Adults' Skills:

  "The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions". (Healthy People 2010)

• Our Expectations and System Demands:

  Managing medications, remembering and following spoken and written directions, interpretation.

Two arrows point down from these boxes to an oval captioned "Health Literacy."

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Patient-Level Consequences

• Poorer health outcomes.
• Increased hospitalizations.
• Greater use of emergency care.
• Missed prescription refills.
• Difficulty understanding medication instructions and warning labels:
  • Inappropriate dosing or timing of meds.
  • Failure to recognize side effects or drug interactions.

Source: 1) Agency for Healthcare Research and Quality. Health Literacy Interventions and Outcomes: An Updated Systematic Review. March 2011.
2) American Medical Association Foundation. Health Literacy and Patient Safety: Help Patients Understand. August 2007.

Slide 5

Societal and Pharmacy-Level Consequences

Societal Consequences

• Nonadherence:
  • Missed refills.
  • Inappropriate dosing or timing of meds.
  • Failure to recognize side effects or drug interactions.
• Increased emergency department costs among low health literacy patients.
• Undermines efforts to increase patient self-management and engagement in care.

Pharmacy-Level Consequences

• Impact on customer loyalty/satisfaction.
• Decreased profits due to missed refills.
• Liability—NYS settlement for LEP patients.

Sources: 1) AMA (2007); 2) AHRQ (2011).

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Communication Strategies

Slide 7

Opportunity: Pharmacists are Trusted Resources

Opportunities for Interactions

• Medication Therapy Management (MTM).
• Dispensing.
• Counseling.
• Other Pharmacy Services.

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Apply Universal Precautions

Everyone benefits when communication is clear:

• Looks can be deceiving. Offer help to all.
• Worry or illness can cloud understanding.
• Offer clear explanations.
• Check to see if you have been clear.

Source: DeWalt D.A., Callahan L.F., Hawk V.H., Broucksou K.A., Hink A., Rudd R., Brach C. Health Literacy Universal Precautions Toolkit. AHRQ Publication No. 10-0046-EF. Rockville, MD. Agency for Healthcare Research and Quality. April 2010.

Slide 9

Recall the Findings from Education Studies

Nearly 9 out of 10 adults have difficulty using the everyday health information that is routinely available in our health care facilities, retail outlets, media, and communities.
(Kutner et al., 2006)

Slide 10

Recognize Patients Who Need Extra Help

Look for Common Signs
Patients who...

• Do not know the name of their medicine but rely instead on shape, size, or color.
• "Forgot their glasses".
• Delay in picking up medicines or renewals.
• Have problems asking questions or explaining their concerns.

Help out

• A lot of people have trouble reading labels and remembering how to take their medications:
  • Is this a problem for you?
  • How can I help?"

Source: 1) Weiss, BD. Epidemiology of Low Health Literacy. In: Schwartzberg JG, VanGeest JB, Wang CC, eds. Understanding Health Literacy: Implications for Medicine and Public Health. AMA Press; 2005:19.
2) Katz MG, Jacobson TA, VeledarE, Kripalani S. Patient Literacy and Question-Asking Behavior During the Medical Encounter: A Mixed-Methods Analysis. Journal of General Internal Medicine 2007;22(6):782-786.8 Found in: Kripalani, Jacobson (2007)

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Recommended Strategies to Improve Communication

1. Explain things using everyday words.
2. Focus on and repeat key messages/actions.
3. Use a "teach back" or "show me" technique to check clarity and understanding.
4. Encourage questions.
5. Use patient-friendly educational materials.

Source: 1) Weiss BD. Health Literacy: A Manual for Clinicians. American Medical Association and American Medical Association Foundation; 2003.
2) Kripalani S, Henderson LE, Chiu EY, Robertson R, Kolm P, Jacobson TA. Predictors of Medication Self-management Skill in a Low-literacy Population. Journal of General Internal Medicine 2006;21(8):803-900. Found in: Kripalani, Jacobson (2007).
3) AHRQ Health Literacy Universal Precautions Toolkit.

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1. Explain Things Clearly in Everyday Words

• Slow down the pace of your speech.
• Use plain, non-medical language:
  • "Blood pressure pill" [instead of "antihypertensive"].
• Include key information about timing:
  • Morning, noon, night, bedtime [instead of 4X a day].
• Avoid jargon:
  • "Take 2 hours before lunch or 2 hours after lunch [instead of "Take on an empty stomach"].

Source: 1) Kripalani, Jacobson (2007); 2) AHRQ Universal Precautions Toolkit (2010).

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Use Everyday Words:

Instead of: → Choose

• Utilize ... Use.
• Adverse reaction ... Side effect.
• Hypoglycemia ... Low sugar.
• PRN ... When you need it.
• Suppository ... Medication that goes in your bottom.
• Topical ... On the skin.

Source: Kripalani, Jacobson (2007).

Slide 14

2. Focus on & Repeat Key Messages/Actions

• Limit information.
• Focus on 1-3 key points.
• Develop short explanations for common medical conditions and side effects.
• Discuss specific behaviors rather than general concepts.
• What the patient needs to do.
• Review each key point at the end.

Source: 1) Kripalani, Jacobson (2007). 2) AHRQ Health Literacy Universal Precautions Toolkit.

Slide 15

3. Use a "Teach-Back" Check for Clarity & Understanding

Image: A chart depicts the Teach-Back model, a circular process in which the clinician explains a concept, assesses patient recall and comprehension, then clarifies and tailors the explanation.

Slide 16

Teach-Back Scripts

• I want to make sure I explained everything clearly. If you were trying to explain to your husband how to take this medicine, what would you say?
• I want to be sure I mentioned the main side effects of this new medicine. Could you tell me the two things to watch out for?
• Show me how you would use this inhaler so I can make sure I explained it well.

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4. Encourage Questions & Interaction

Do Ask:

• What questions do you have?
• How can I make it easier for you to take your medicines?
• Did anyone explain what to do if you miss a dose?

Don't Ask:

• Do you have any questions?
• Questions?

Source: Kripalani, Jacobson (2007).

Slide 18

5. Use Patient-Friendly Materials

Characteristics:

• Key information is offered.
• The material is a tool for action.
• The content is designed to help action steps.
• Everyday words are used.
• The design eases reading.
• Relevant illustrations are used [show how-to].
• Evidence that the designers tested it with audience members.

Source: Kripalani, Jacobson (2007).

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Patient-Friendly Materials Simplify Tasks

Image: A photograph shows a collection of medication bottles.

Slide 20

Use Patient Friendly Materials

Image: A sample medication bottle is shown with confusing instructions: "Take two tablets by mouth twice daily."

Slide 21

Use Patient Friendly Materials (cont'd)

Image: A sample medication bottle is shown with more explicit instructions: "Take 2 pills by mouth at 8 am and 2 pills at 6 pm."

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Summary

To make sure I've explained things clearly so far...

• How do you know if a patient has limited or low health literacy?
• Name at least 2 techniques to improve communication with low-literacy patients.
• Provide an example of the teach-back.

Slide 23

 

Active Learning Exercise

• Divide into groups of three. Each person in the group will have a role to play:
  • Pharmacist.
  • Patient.
  • Observer.
  .
• Refer to the handouts for instructions for each role.
• After each round, the "observer" will provide feedback to the "pharmacist."
• Switch roles after each round. Each person should have a chance to play the pharmacist.

Slide 24

Role Play Discussion

• What was different?
• Was it hard?
• What did you learn?

Slide 25

Wrap Up

• Build on existing trust:
  • Encourage dialogue and questions.
• Adopt Universal Precautions.
• Improve Communication:
  • Plain Language (everyday words, no jargon).
  • Focus on Key Messages.
  • Teach Back.

Slide 26

References

• Agency for Healthcare Research and Quality. Health Literacy Interventions and Outcomes: An Updated Systematic Review. March 2011. Available at:
• American Medical Association Foundation. Health Literacy and Patient Safety: Help Patients Understand. August 2007. Available at: .
• Centers for Disease Control and Prevention Health Literacy Training for Public Health Professionals: .
• Davis T.C., Wolf M.S., Bass P.F. 3rd, Thompson J.A., Tilson H.H., Neuberger M., Parker R.M.. Literacy and misunderstanding prescription drug labels. Annals of Internal Medicine, December 2006. 19;145(12).
• DeWalt D.A., Callahan L.F., Hawk V.H., Broucksou K.A., Hink A., Rudd R., Brach C. Health Literacy Universal Precautions Toolkit. (Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, under Contract No. HHSA290200710014.) AHRQ Publication No. 10-0046-EF) Rockville, MD. Agency for Healthcare Research and Quality. April 2010.

Slide 27

References (cont'd)

• Kirsch, I., Jungeblut A., Jenkins, L. and Kolstad, A. (1993) 'Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey (NALS)', National Center for Education Statistics, U.S. Department of Education, Washington, DC.
• Kutner, M., Greenberg, E. and Baer, J. (2005) 'A First Look at the Literacy of America's Adults in the 21st Century', National Center for Education Statistics, NCES 20062470, Washington, DC.
• Kripalani, S. & Jacobson, K. L. (2007). Strategies to improve communication between staff and patients: Training program for pharmacy staff. Rockville, MD: Agency for Healthcare Research and Quality.
• Spector S.L. and Youdelman, M. Analysis of State Pharmacy Laws: Impact of Pharmacy Laws on the Provision of Language Services. National Health Law Program (2010).
• Warholak T.L., Nau D., (Editors). Quality & Safety in Pharmacy Practice. New York, NY: McGraw-Hill Medical; 2010.
• Warholak T.L, West D., Holdford D.A. Educating Pharmacy Students and Pharmacists to Improve Quality. Journal of the American Pharmacists Association (2003). 2010 Jul-Aug;50(4):534-8.

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