Curricular modules teach budding pharmacists how to engage patients with low health literacy
Research Activities, May 2012, No. 381
The statistics on health literacy are startling. A Department of Education assessment found that only 12 percent of adults have enough health literacy to understand and use health information effectively. And more than one-third of adults have "basic" or "below basic" health literacy, which means they might not understand labels of over-the-counter medicines. But the reality is worse.
Because health literacy can affect just about all of us, says AHRQ's lead on health literacy Cindy Brach, M.P.P. "I like to say, 'Health literacy is a state, not a trait,'" says Brach. Under certain circumstances—for example, a devastating diagnosis of a loved one or ourselves—any patient's comprehension can plummet, explains Brach. "All of us have a health literacy story about ourselves, or our mothers, or grandmothers."
Her own story?
"I got a call from my doctor's office about an abnormal pap smear," Brach told Research Activities. "I was told that I had a nonsquamous epithelial lesion."
She knew what to ask: "Do I have cancer? Is this precancerous? What is my risk of getting cancer?" But her questions didn't help, because the person who called couldn't answer in a way she could understand. Brach says, "I'm a health literacy expert, but when I looked this up, I was so anxious I misread the chart. I thought I had a high risk of getting cancer." It turned out that Brach was at increased risk, but her risk was still very small.
She tells the story of a colleague who picked up his father from the hospital after surgery. The discharge nurse gave the father a disc with instructions on how to inject himself with a blood thinner. "It wasn't until they reached the car that the father realized he had a problem," says Brach. "He didn't own a DVD player."
"Poor communication practices resonate with people in a very personal way," says Brach.
Role of the Pharmacist
For many patients, the last chance to get the personal help they need might be the clinician who is available without appointment every day of the year—the pharmacist.
"Pharmacists have a real opportunity to provide health literacy-appropriate communication on medications," says Sarah J. Shoemaker, Pharm.D., Ph.D., health services researcher at Abt Associates and adjunct assistant professor at Massachusetts College of Pharmacy and Health Sciences. "Not only have pharmacists become more patient-centered in recent years, but Medicare Part D mandates medication therapy management, which is largely provided by pharmacists."
In 2009, AHRQ launched a health literacy site for pharmacists, which includes instructions on how to develop pictorial drug cards for patients and telephone reminder calls, training for pharmacy staff, and more.
After studying pharmacists' experiences using an assessment tool for evaluating a pharmacy's health literacy practices, the Agency discovered that pharmacy students and residents were the people most likely to use the tool. Armed with this information, AHRQ developed curricular modules with slide decks and activities for pharmacy faculty, students, and residents to learn techniques to help patients with limited health literacy that can benefit everyone (http://www.ahrq.gov/pharmhealthlit/).
"We can use well-established techniques with everyone," says Shoemaker. "It's not a matter of picking out those who have health literacy issues, because you can't tell who they are. Looks can be deceiving."
The "teach back" method
The modules explain "teach back" and "show-me" methods, ways for clinicians to confirm understanding when patients explain information back in their own words or demonstrate what to do.
"It's a universal precautions approach," says Shoemaker. "Everyone benefits when we communicate well."
Pajnhiag Nengchu, Pharm.D., was one of those students who used the AHRQ assessment tool. As a pharmacy resident at the University of Minnesota, Nengchu needed a project, and the AHRQ assessment was natural for her. "English is my second language, so health literacy is very important to me," said Nengchu, whose first language is Hmong. Through the assessment tool, Nengchu noticed a gap in awareness about health literacy at the pharmacy where she was a resident. "The pharmacists put a lot of time into making sure the patients have pamphlets in their own language, but the technicians didn't have as much of a grasp on health literacy," said Nengchu. She also noticed a difference when the staff gave directions in person versus over the phone. "They were better in person," she said. "It would have helped to give landmarks and know bus routes for people calling."
But Nengchu knows it's not always easy to help. When Nengchu was about 20, she worked as a technician at a pharmacy. "One day this little old lady who spoke a different language came in with a prescription for eyeglasses," says Nengchu. "She kept saying, 'This is a prescription,' and I'd say, 'Yes, but we don't cover eyeglasses.'" Now, Nengchu knows approaches that might have helped. "I might have drawn pictures or I could have drawn a map with a picture of the mall next door where she could have gotten the prescription filled, or I could have looked up an eye doctor's name in that mall."
Currently a pharmacist at a military hospital in Hawaii, Nengchu uses health literacy skills every day. "When I talk to patients, I explain things in a way to get feedback, and I ask open-ended questions so that I don't make any assumptions about their knowledge. "I ask every kid who uses albuterol [an inhaler for asthma] to show me how to use it, and almost every single time, there's something they can do better," she says.
When patients come in for Coumadin® [Warfarin], a drug that prevents clot formation, Nengchu asks, " 'Do you know what to do if you miss a dose?' Patients don't always know when they're at increased risk for bleeding and bruising."
"My take-home message is, you really don't know what the patient knows until you ask for the 'teach back.'" As an associate professor and guest lecturer, Michael J. Miller, R.Ph., Dr.P.H., F.A.P.H.A, teaches faculty, students, pharmacists, and clinicians around the country about the importance of health literacy. He also served as a faculty advisor for AHRQ's health literacy curricular modules for pharmacy faculty.
As a graduate student between 1999 and 2004 who wanted to write his Ph.D. dissertation on health literacy, Miller said, "The topic was relatively new, and I had to practically beg people to be on my [dissertation review] committee." The health literacy issue resonated with Miller, whose father didn't finish high school.
"When my father had Class IV heart failure and had exhausted his treatment options, he was invited to be in a research study," said Miller. "My dad came home with this lengthy consent form, looks at me and asks, 'Should I participate?' He had to ask his child because he didn't understand the consent."
"Health literacy isn't handing someone a form or stapling uninterpretable information on a bag and assuming they can read, understand, and act on it," says Miller. "There isn't a substitute for oral communication between health care providers and patients."
The pharmacy environment
But Miller acknowledges how difficult it is to communicate—especially in a pharmacy. "Pharmacy environments are not conducive to communication. They are often designed for convenience, and we are responsible for this culture," says Miller. "People come in for a gallon of milk, a birthday card—and a prescription."
When Miller and his colleagues evaluated pharmacies using the AHRQ pharmacy assessment tool, he found that "patients usually don't have a complaint. They seem pleased with convenience. If they have a question, they get an answer. Pharmacies are very passive environments and often depend on patients to ask questions." They can also be confusing. "Just walk down an aisle with over-the-counter medications and look at how much stuff is packed in a very small area. How do patients identify the products that are best for their needs? Moreover, do they understand what to expect from the treatment without adequate counseling?" Miller says, "We've come a long way in the last 10 years so that health literacy is now well recognized as fundamental to health care safety, quality, and patient-centeredness."
Yet when Miller speaks to groups of pharmacists, he often shares a story that doesn't involve a pharmacy. He tells about purchasing jewelry for his wife after 20 years of marriage. "I'd never bought my wife a diamond before, and I didn't know anything about gold or silver," Miller admits. "The jeweler showed me something called Pandora jewelry, which involved selecting spacers, clasps, silver and gold, charms." At the end of the purchase, Miller says, "The jeweler spent an hour with me, I didn't know anything about the stuff, I was embarrassed and afraid to ask questions, and I'd just spent somewhere between $1,200 and $1,400." Miller then makes his point. "In health care, we use language and terminology that is very complicated, and when we're misunderstood we have a tendency to blame the patients—who often feel like I did in the jewelry store."
As Shoemaker says, "At the end of the day, it's communication that's so important." You might even say it's golden.