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Objective

This training program is designed to introduce pharmacists to the problem of low health literacy in patient populations and to identify the implications of this problem for the delivery of health care services. The program also explains techniques that pharmacy staff members can use to improve communication with patients who may have limited health literacy skills.

Suggested Audience

This program is intended for pharmacy staff members who regularly interact with patients and provide them with health information. This includes both pharmacists and pharmacy technicians. Other pharmacy staff members who interact with patients may also benefit from this training.

Materials Provided

The training materials provided with this program include:

• PowerPoint® Presentation (PowerPoint® File, 380 KB; ).
• Handouts for the final section to practice of techniques in the slides (Web Version; PDF File, 245 KB, ).
• Reference List.

Format of Program

A slide set is included for presentation of the material. Notes for the trainer are included with each slide, and these may be viewed electronically by choosing View –› Notes Page after opening the PowerPoint slide set document.

The last section of the training lets participants practice the techniques presented. The handouts for this section are also included. The participants will split into groups of three. Each group will get one copy of each handout (instructions for pharmacist, patient, and observer roles). This is a role-play exercise in which everyone with the "pharmacist" role will practice counseling the "patient" using the clear health communication techniques covered in the presentation. The "observer" will provide feedback to the "pharmacist." After each round, members of each group should switch roles. All three people in each group should have a chance to act as the pharmacist. This exercise will require about 15 minutes total.

After completing the role-play exercise, the group should re-convene. The trainer can use this time to ask for feedback on the role-play exercise, answer any questions that participants may have, and emphasize take-home messages.

Suggested Agenda

This program will require about 2 hours to present. A suggested agenda for the program is:

1. Welcome and Introductions: 10-15 minutes
2. Interactive Delivery of Slide Set: 1 hour
3. Small Group Breakout Sessions: 15 minutes (Role Play Exercise Using Handouts)
4. Question-and-Answer Session and Wrap-Up: 30 minutes

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 Slide Set and Notes for the Trainer

Slide 1: Strategies to Improve Communication Between Pharmacists and Patients

Select for text description for slide 1.

[Introductions: Please have participants introduce themselves. During their introduction, ask them to share an experience during which a patient had difficulty understanding something about their medications, or made an error due to misunderstanding.]

Slide 2: Training Curriculum for Pharmacy Staff

Select for text description for slide 2.

[This training program was originally developed by researchers at Emory University in Atlanta, GA. The PILL study – Pharmacy Intervention for Limited Literacy - was funded by ´óÏóÊÓƵ and the Robert Wood Johnson Foundation. The training program is part of a larger study addressing health literacy systems-based interventions.

We are using this program to identify ways in which we can better communicate with our patients.]

Slide 3: Overview

Select for text description for slide 3.

Let me share with you what we'll be covering in our training today. When you leave here today, I want you to able to:

[State learning objectives here]

• Define health literacy.
• Describe the health care experiences of low-literacy patients.
• Discuss health literacy and medication use.
• Review techniques to improve communication with low-literacy patients.
• Have an opportunity for hands-on practice!

Adult learners learn best by doing. This is where our hands-on activity comes into play.

Slide 4

Definition

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Everyone is probably familiar with the definition of literacy– the ability to read and write, but what about Health Literacy?

Health Literacy refers to a constellation of reading and numeracy skills required to function in the health care environment.

These include:

• Reading prescription bottles.
• Figuring out appointment slips.
• Understanding informed consent documents.
• Understanding discharge instructions.
• Following diagnostic test instructions.
• Reading health education materials.
• Completing health insurance applications.

Health literacy is context specific. Someone who has excellent reading and writing skills, and who functions very well in another environment (for example, an accountant), may still have low health literacy.

Slide 5

Health Literacy in America: Results from the NAAL

[D] Select for text description.

The National Assessment of Adult Literacy (NAAL) provided the first measure of our country's health literacy. This household survey found that 14% of American adults function at the below basic level, 22% function at the basic level, 53% have an intermediate level of health literacy, and 12% have proficient health literacy. Note that interpreting medication labels requires intermediate skill. This means that 36% of adult Americans have levels of health literacy below what is required to understand typical medication information.

Slide 6

High Risk Groups

[D] Select for text description.

Certain groups are more likely to have limited health literacy. These groups include...

However, it is important to remember that low health literacy is a problem that touches all groups and segments of society. In terms of raw numbers, most people with low health literacy are White.

Slide 7

Functional Literacy of High Risk Populations

[D] Select for text description.

Here are some figures from another national study which looked at general literacy skills.

Of those aged 65 or greater, 81% have low literacy. Blacks and Hispanics are more likely to have low literacy: 77% and 78% compared to 41% of Whites. Those with the least amount of education have the highest prevalence of limited literacy.

Slide 8

Overview

[D] Select for text description.

Now, let's talk about how it might feel to be a patient who has trouble understanding medical information.

Slide 9

Health Care Experiences

[D] Select for text description.

You can't tell by looking. Patients are very savvy in masking the signs of limited health literacy, as there is a great deal of shame associated with this. In fact, one study found that 24% of individuals who suffered from limited health literacy had never informed their spouse (Parikh et al. 1995).

Patients with limited health literacy skills may be very articulate, and smart enough to navigate through life and the health care environment with these limitations.

Tell me, when do you suspect a patient has low health literacy? What are some of your experiences with low-literacy patients?

Slide 10

Possible Indicators of Low Health Literacy

[D] Select for text description.

Some excuses you may hear from patients with low health literacy include:

"I forgot my glasses. I'll read this when I get home."
"I forgot my glasses. Can you read this to me?"
"Let me bring this home so I can discuss it with my children."

Other possible red flags for low health literacy are:

• Lack of follow-through – incomplete forms/missed appointments.
• Patients cannot describe how to take their medications, have difficulty explaining medical concerns, or seldom have any questions.

Slide 11

Universal Precautions

[D] Select for text description.

Because we can't tell by looking who is affected by low health literacy, we advocate using a Universal Precautions approach – that is, simplify information for everyone, independent of their perceived health literacy abilities. By simplifying information for all and assuming that most patients may have difficulty in understanding the information, we are paving the way for improved communications and, hopefully, improved adherence and health outcomes.

Slide 12

Overview

[D] Select for text description.

Now, let's transition to what is known about health literacy and medication use.

Slide 13

Low Literacy and Medication Use

[D] Select for text description.

Several studies have assessed patients' understanding of their medications.

In these studies, researchers found that individuals with limited health literacy demonstrated:

• 12 to 18 times the odds of being unable to identify their own medications and distinguish one from the other.
• Common difficulty understanding simple instructions such as taking a medication every 6 hours or on an empty stomach.
• Worse understanding of common drug mechanisms and side effects, such as how warfarin works (despite being on warfarin and having attended educational classes on its use).
• Greater misinterpretation of drug warning labels.

Slide 14

Misinterpretation of Warning Labels

[D] Select for text description.

Now, let's review some important health communication messages about drug warnings and patient safety. First, we find that warning labels are not regulated, and many have not been updated since the 1960s.

Dr. Terry Davis and colleagues conducted a study where she identified concerning misunderstandings of warning labels by patients. Let me share a few of these with you.

Slide 15

Health Literacy and Medication Use

[D] Select for text description.

Other research studies have found that patients with low health literacy had:

• Greater difficulty understanding numerical information, such as INR levels for monitoring warfarin use.
• Lower medication adherence, though not all studies have shown this. One study showed that the majority of patients were non-adherent because they didn't understand their medication regimens.
• Anecdotal evidence of making mistakes with their medications and experiencing more adverse drug events (though this, too, is not consistently supported in research).
• Higher health care costs, due in part to greater use of Emergency Departments and higher hospitalization rates.

Slide 16

Some Challenges in Trying to Improve Things

[D] Select for text description.

Greater demands are being placed on our patients as consumers of health care.

The health care system is increasingly complex and demanding of patients – from direct-to-consumer advertising to shorter hospitalizations with greater self-care requirements after discharge. At times, physicians may actually place greater burdens on patients, such as in the process of informed decision-making for prostate cancer screening.

Most patient instructions are written. There is a consistent gap between the reading demands of the health care setting and the actual skills of many Americans. For example, the average American has an 8th grade reading level, while the average medical/health information is written at at least a 12th grade level.

Verbal instructions are often complex, rushed, and given at a time when patients and their families are stressed by illness.

Slide 17

What questions do you have?

[D] Select for text description.

Let's pause to check in and find out what questions you have so far...

Slide 18

Overview

[D] Select for text description.

Now let's shift gears to discuss techniques that you can use in your day-to-day interactions with patients that will improve communication, especially for those patients who have limited literacy skills.

Slide 19

Recommended Strategies to Improve Communication

[D] Select for text description.

All patients, not just those with low health literacy, will benefit from these 5 recommended strategies for patient-centered visits:

Using plain language is not easy for us as clinicians. Make a conscious effort to avoid medical jargon and vague instructions.

• Keep it short and simple. Only tell patients what they need to know, not what is nice to know.
• There is a growing body of research suggesting that asking patients to "teach back" what they have learned improves medical outcomes. This was recently listed as one of the top 11 patient safety practices for reducing medical errors (National Quality Forum 2003, Shojania et al. 2001).
• Most pharmacists probably feel that they give patients a chance to ask questions, but some simple techniques can enhance patients' comfort level in asking questions.
• Because everyone has different learning styles, verbal messages should be reinforced with written information and pictures whenever possible. Everyone learns better if information is reinforced in multiple ways. Provide easy-to-understand information for all patients.
• Together, these strategies and others will help ensure the environment is patient-friendly and shame-free for all patients.

Slide 20

Explain Things Clearly in Plain Language

[D] Select for text description.

Think about how much easier it is for you to understand new information if it is presented a little more slowly.

Concrete examples or analogies can help give a sense of reality to abstract concepts or things that patients can't see in their own body.

Also pay attention to the patients' own terminology and use those terms yourself in the discussion.

Be careful about vague things that you are accustomed to saying in your counseling. Just what exactly does it mean to take a medication on an empty stomach. Be as specific as possible when providing instructions.

Slide 21

Using Plain Language: What could we say instead of...

[D] Select for text description.

Let's practice a few simple alternatives to common jargon that may come up in medication counseling.

Slide 22

Focus on Key Messages and Repeat

[D] Select for text description.

• Limit information.
  • There's a tendency to try to explain everything to a patient at one visit. In most cases, the patient will actually be better off if you select just a few key points, reinforcing and repeating them during the discussion. Less is more.
  • In choosing the points to address, try asking the patient to identify the 1 or 2 most important things to them. Patients are far more likely to remember the answers to their own questions and concerns. This strategy will also reduce the "by the way..." questions as you are wrapping up your patient counseling.
  • You could combine the patient's 1-2 priority items with your top 1-2 things to develop a manageable list of just a few things to discuss. The patient's concerns might be the same as yours, or they could be totally different.
• Develop short explanations for common conditions– how can you explain a diabetes medicine in 2 or 3 brief sentences?
• Focus on behaviors- what do you want the patient to do?
• Review each point at the end– summarize and reinforce.

Slide 23

Use a "Teach Back" to Check Understanding

[D] Select for text description.

How many of you know the teach back principle?

• Well, teach back is used to assess patient understanding. Asking patients to repeat something in their own words is a far better way to gauge comprehension than simply asking, "Do you understand?"
• Let me walk you through this diagram. After explaining a new concept, we should assess the patient's recall and understanding, clarify our explanation as needed, reassess comprehension, and continue to clarify until the patient expresses satisfactory understanding.
• Most of us who have performed a teach back assess patient recall and comprehension the first time, but if we need to clarify or tailor the information, rarely we re-assess patient comprehension. This is the most common mistake made when attempting to apply the teach back model.
• In one study, physicians who used the teach-back technique with their diabetic patients achieved better glycemic control. Teach back works.

*Note: the process shown in this diagram may be modified as needed in each patient encounter. The cycle may repeat as many times as is necessary for sufficient patient recall and comprehension.

Slide 24

Teach Back Scripts

[D] Select for text description.

When asking patients to "teach back", it helps to put them at ease by placing the burden on yourself. You want to know what information the patient understood.

You also need to focus the teach back on 1 or 2 points. If I asked you right now to tell me what I have shared with you in the last hour, you might recall 1 or 2 concepts, but this is not effective for assessing your knowledge. It would be more effective for me to assess your understanding of the impact of health literacy. I might say, for example, "We have covered a lot of information today. In order for me to be sure that I explained health literacy correctly (placing the burden on myself), tell me two things you can do to improve communications with patients (focuses the teach back on 1 point)."

What are some other ways you can ask for a teach back?

Slide 25

Effectively Solicit Questions

[D] Select for text description.

As pharmacists wrap up a patient encounter, they often solicit questions from the patient, in part to check patient's comprehension of the information that has been covered.

Unfortunately, we often do this in a closed-ended way with a yes/no prompt such as:

• "Do you have any questions?"
• "Any questions?"

Remember, patients are often hesitant to admit that they don't understand something or they're afraid to ask what might be considered a "stupid question."

This is most true for patients with low health literacy. Open the door for them by effectively soliciting patient questions. Ask, "What questions do you have?"

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