Empowering patients with limited health literacy

A patient with severe cardiovascular disease (CVD) was taking a number of prescribed medications, including nitroglycerin sublingual tablets and ranolazine. To assess the management of the patient’s CVD during a complete medication review, Salvatore J. Giorgianni, Jr., PharmD, BSc, CMHE, asked him how often he had to use the nitro-sublingual medication. The patient replied that he needed to use nitroglycerin more frequently, about twice to three times weekly. Concerned that the patient was having so many angina attacks while taking ranolazine, Giorgianni questioned him further and discovered that he had misunderstood the label, which directed, “Take one a day for chest pain.” The patient was taking the preventative agent ranolazine only when he felt chest pain and not once daily, as intended.                                                               

“We often get caught up with imprecise language in preparing prescription labels, and imprecision can lead to confusion in patients with low literacy or who simply are confused by all that is happening to them,” said Giorgianni in the white paper “Health literacy, medication adherence, and pharmacist interventions,” recently released by Pharmacist Partners. Giorgianni works for a compounding pharmacy in Florida and is an advisor to Pharmacist Partners, a Clinical Knowledge Organization specializing in enhanced medication compliance among patients through its partnerships with drug manufacturers.  

In sharing the white paper with Drug Topics (it can be downloaded from the website www.pharmacistpartners.com), the company expanded upon the root causes of low and limited health literacy in the U.S. population and offered solutions for pharmacists seeking to increase medication adherence through interventions personalized to specific patients. 

Scope of the problem

The 2003 National Assessment of Adult Literacy (NAAL), a federally funded census of adult literacy, was launched to determine the change in levels of English literacy in the United States between 1992 and 2003. More than 19,000 adults were surveyed at the national and state level, including 1,200 prison inmates.

The results demonstrated that 93 million U.S. residents (43%) have basic or below basic literacy. These participants could read short text and find a single piece of information identical to information contained in a question. They could not find and interpret information that was in dense or lengthy text with no organizational headings, could not understand multiple text sections, could not find and interpret information from complex tables and graphs, and had difficultly finding numbers in text. They also had limited quantitative reasoning skills.

Lisa Gale Van BrackleIn 1992, the National Adult Literacy Survey (NALS), an earlier project to assess adult literacy in the United States, found that 77 million people (more than a third of American adults) had trouble with some basic tasks for their healthcare, “such as following directions on a prescription drug label or adhering to a childhood immunization schedule using a standard chart,” said Lisa Van Brackle, PhD, MSW. The primary author of the white paper, she has more than 20 years of experience in the design and implementation of social programs for disadvantaged populations.

Of the participants in the NALS, 25% were immigrants with limited access to employment and education, and 26% had physical, mental, or health conditions. One-third were elderly, defined as older than 65 years of age. Among those who scored at the lowest literacy level (level 1), 40% were in poverty, 50% were unemployed, and only 30% were employed full-time.

The main groups in the nation with limited literacy include U.S. residents with limited access to education, immigrants for whom English is not the first language, and older adults. These are the same groups that show limited health literacy, noted Van Brackle, who has managed programs for TV411, a television based, multimedia project of the Adult Literacy Media Alliance and provided training to adult literacy instructors for the Literacy Assistance Center.

Implications of limited health literacy

The NAAL data were analyzed, and a report published in 2006 by Mark Kutner of the National Center for Education Statistics and colleagues concluded that almost “90% of adults have difficulty using the everyday health information that is routinely available in our healthcare facilities, retail outlets, media, and communities.” In addition, they found that about three-quarters of U.S. adults with long-term illnesses have limited literacy and difficulty understanding their disease states and what to do about symptoms.

In 1999, Catharine Selden of the National Library of Medicine and colleagues, reported in an article titled “Health Literacy: January 1990 – January 1999,” that literacy and functional health literacy are closely associated. Those individuals with low functional health literacy have difficulty reading and understanding prescription labels, appointment reminders, and other health materials that providers expect functionally literate patients to comprehend.

Low and limited health literacy carries a large cost to society. In 2003, costs associated with health literacy reached between $106 and $236 billion annually. When adjusted for inflation, the annual U.S. costs range from $134 to $299 billion, according to Lynn Nielsen-Bohlman, of the Institute of Medicine, and colleagues.

Interventions for improved medication adherence

Health literacy interventions should focus on improving communication between the patient and the provider.

Information designed to increase understanding of what constitutes good health includes written information found in both the healthcare setting and community venues such as health fairs, public libraries, and governmental agencies. Information about good health can be presented during a doctor or pharmacy visit. It is also available through various media channels, including television, radio, and the internet.

“Interventions that make accommodations for low literacy by, for example, increasing awareness of information about health or healthy behaviors, using videos, illustrated, or other materials developed with a mindfulness of low literacy, and verbal teaching using simplified language have proven to be effective,” Van Brackle said in the white paper.

Use of simpler language, shorter sentences, good syntax, and understandable graphics go a long way in conveying health information to individuals with low health literacy.

In her work at New York City’s Literacy Assistance Center, Van Brackle secured a contract to provide health literacy training to clinical and support staff of New York City’s Health and Hospital Corp. The goal was to elevate awareness of health literacy issues and their prevalence among the patient population, and to start a dialogue on how to address them.

The year-long program, which Van Brackle directed six years ago, offered a variety of sessions for all segments of the healthcare system, including physicians, nurses, nursing assistants, social workers, medical informatics practitioners, and support staff not directly involved in patient care.

“We included all different workers, including transport workers who look very much like the patient population,” Van Brackle told Drug Topics. “When patients are in a facility and they are scared and don’t know what to do, they are going to go to someone who looks like them. So we wanted to provide some kind of support - not just to healthcare professionals who also need help - but also to these other individuals, so they would be in a position of helping patients without diminishing them or ignoring them.”

Strategies that work

Van Brackle noted some effective strategies for use with families of patients being treated in the emergency department.

Family members are often afraid and can’t hear what the healthcare provider is saying at first, she said. So it is important to acknowledge their emotions and to speak slowly. If the family member doesn’t speak the same language as the healthcare professional, the healthcare worker may have a tendency to speak louder instead of more slowly.

After distilling what is happening and what needs to be done for the patient, the healthcare professional should ask the family member, “What did you hear?” and wait for the family member to summarize what was said. The healthcare professional then needs to ask, “What are you going to do next? What steps are you going to take?”

Helpful aids for patients in the healthcare setting include forms and documents written at a sixth-grade level, as well as hospital signage that is understandable and easy to navigate.

Some hospitals assign a nurse or community health worker to help patients with low or limited literacy. These staffers attend appointments to acquaint themselves with management of the patient’s condition(s), provide patients with phone reminders to pick up prescriptions at the pharmacy, and help with follow-up. Because costs are associated with this model, it is not a widely used practice among health systems, Van Brackle noted.

Other helpful tools to support patient medication adherence include pillboxes individualized for the different days of the week as well as for times of day. These are particularly helpful for patients with complex drug regimens.

“There is a movement to also use pictures on prescription bottles. Graphics can show that you should take the medication on an empty stomach. If you need to take it at the beginning of the day, the graphic will be the sunshine,” said Van Brackle.

Improved adult learning

Individuals with low or limited health literacy can have significant deficits connected with medication adherence. Patients can misinterpret prescriptions; they can have trouble identifying medications; they can experience difficulty understanding how to take medicine; and they can have poorer short-term memory.

To improve the odds that patients will understand and adhere to their medication regimens, the principles of William Glasser’s work on adult learning have stood the test of time.

Khrys KantarzeGlasser’s work has demonstrated that “adults maximize learning through hearing, seeing, and doing, with a combination of these three elements giving optimal results. Glasser’s work [has remained] the industry standard … for over five decades,” according to Khrys Kantarze, BS, MS, a certified training and development professional, and vice president of talent management at Pharmacist Partners.

Pharmacists can greatly improve their communications pertaining to medication adherence by understanding adult learning processes and bearing in mind the rate of retention that corresponds to each method.

Adults who read new information will retain 10%. Those who hear new information will retain 20%. Individuals who see new information will retain 30%. However, if pharmacists and patients discuss new information, patients will retain 70%. The best results are seen with adults who experience new information (80% retention rate) and with adults who can show or teach it to someone else (95%), said Kantarze.

“In the healthcare setting, the trainer will demonstrate something, so the trainee will retain 30% of that information. Then the trainer will have the trainee do what is called ‘return demonstration.’ The trainee will show the trainer that he or she can do it, which is experience, so you have an 80% retention rate,” she said.

In the pharmacy, return demonstration also can be easily employed, taking only about five minutes. For example, if the subject is insulin administration, the pharmacist can demonstrate how to draw up insulin through a dummy syringe, and then the patient can demonstrate the task to the pharmacist. “The corporate offices could [initiate] this, and lead their pharmacists this way,” Kantarze said.

In the pharmacy that Kantarze uses, she witnessed a Hispanic mother picking up her prescriptions. Her 8-year-old child, who spoke English, accompanied her and acted as the translator. The pharmacy technician interacted with the child.

“Of course, the pharmacy technician said to the child, ‘Do you have any questions [about the medication]?’ ” Kantarze said. “And, of course, the answer was no. Using Glasser’s adult learning principles, I would have done this instead: ‘Let me explain this medication to you, and then you explain it to your mother and have your mother explain it back to you. Then you tell me [what she said].’”

The two- to three-minute encounter

Pharmacists are in the best position to conduct an open dialogue with patients to assess their literacy levels, discuss their medications, help them understand the need for the medication, and motivate them over the course of the treatment, said Giorgianni.

When a patient comes in with a new prescription, the pharmacist should consider three questions:

·      What is the patient taking this medication for?

·      What can the pharmacist tell the patient to expect with this medication?

·      Why is it important for the patient to do this?

“This two- to three-minute encounter is what I always have with a person who is picking up his/her medications for the first time,” Giorgianni said. He also has a conversation with patients after reviewing multiple refills that may raise a red flag, including, for example, those individuals who have been prescribed a Zithromax Z-Pak (azithromycin five-day course), for the 15th time. This could be problematic because of the increased risk of antibiotic resistance. If pharmacists see a problem, they should do their due diligence, he said.

While language barriers to medication adherence can be difficult, it is not impossible to overcome them. In the United States, the Hispanic/Latino community has reached more than 50 million and is expected to more than double by 2050, representing 30% of U.S. population. Pharmacists need to take the time to counsel patients who may not speak English or who have limited English proficiency, said Giorgianni.

Personnel. A best practice for community pharmacies includes hiring personnel who reflect the community, such as those who speak the same language as some of the patients using the pharmacy and who understand the culture of those patients. These staff members can help with translation if it is needed, he said.

Family members. Pharmacists can also interact with family members, whose participation is common among members of the Latino population, Giorgianni noted. In a tight-knit community, family members can be extremely supportive as well as helpful in matters of translation. Pharmacists can also ask the patient to have a family member call the pharmacy when the patient returns home. This could help with the patient counseling, he said.

Physical environment. Another best practice for community pharmacies would be to create a physical environment that encourages communication, such as a specific area for private counseling.

Visual aids. For patients with impaired hearing, the pharmacist can use graphically dense material to help explain the patient’s condition and its management, or use a teletypewriter to accommodate these patients. Brochures printed in different languages, such as Spanish, can help describe certain disease states.

A culture of encouragement

“The onus is to create an environment in your pharmacy practice and culture that encourages communication between pharmacists and patients,” Giorgianni said.

“With this white paper, I hope the message comes across that the working pharmacist can counsel patients effectively in three minutes. If you are cautious about whom you counsel and how you counsel, those can be extremely productive three-minute conversations,” he said.

For the owners and managers of community pharmacies, the best approach is to encourage and reward pharmacists for patient counseling focused on improved medication adherence. Not only will this “enhance adherence and compliance; it will enhance the patients’ perspective of community pharmacies as health places as opposed to hybrid retail places,” Giorgianni said.