Overcoming the Impact of Disparities and Low Health Literacy

on Patient Care

Michael J. Miller, DrPH, RPh

Associate Professor

College of Pharmacy - The University of Oklahoma

Sharon L. Youmans, PharmD, MPH, BCPS

Associate Professor

School of Pharmacy - University of California San Francisco

2 2

This activity is supported by an

educational grant from Lilly USA,

LLC. For further information

concerning Lilly grant funding visit,

www.lillygrantoffice.com.

Supported by an independent

educational grant from Merck.

3 3

The American Pharmacists Association is accredited by the Accreditation

Council for Pharmacy Education as a provider of continuing pharmacy

education.

This activity, Overcoming the Impact of Disparities and Low Health Literacy on

Patient Care, is approved for 2.0 CPE credits (0.2 CEUs). The ACPE Universal

Activity Number assigned by the accredited provider is 202-000-12-069-H04-P for

pharmacists and 202-000-12-069-H04-T for technicians. If you participated in the

live seminar of the same title held Saturday, March 10, 2012 at the APhA Annual

Meeting and Exposition in New Orleans, LA you are NOT eligible to receive credit

for this activity.

To obtain CPE credit for this activity, you must view the slides, listen to the entire

audio recording and complete the online post test and evaluation by March 10,

2015. To complete the online activity post test and evaluation form, participants

must have a valid Pharmacist.com user name and password. A Statement of Credit

will be automatically generated upon achieving these requirements.

NOTE: no voucher code is needed when completing the online version of this

course

4 4

Disclosures • Michael Miller has received an honorarium from Abt Associates

for serving on an AHRQ Faculty Advisory Panel for Advancing

Health Literacy Practices through Quality Improvement:

Curricular Modules for Faculty. No other conflicts of interest, real

or apparent, and no financial interests in any company, product,

or service mentioned in this program, including grants,

employment, gifts, stock holdings, and honoraria are declared.”

• Sharon Youmans has received an honorarium from Abt

Associates for serving on an AHRQ Faculty Advisory Panel for

Advancing Health Literacy Practices through Quality

Improvement: Curricular Modules for Faculty. No other conflicts

of interest, real or apparent, and no financial interests in any

company, product, or service mentioned in this program,

including grants, employment, gifts, stock holdings, and

honoraria are declared.”

5 5

Learning Objectives

• Describe the concept of health literacy and variations in federally

recognized priority population subgroups in the United States.

• State a conceptual framework and provide examples for how

low health literacy may contribute to suboptimal health

outcomes in diverse population subgroups.

• List practical literacy-based tools and interventions that can be

translated for use in diverse population subgroups in pharmacy

settings.

• Discuss opportunities to integrate and evaluate health literacy

principles in pharmacy practice settings.

6 6

Please note your answer to the self-assessment question on a piece

of paper. The questions and answers will be reviewed at the

completion of the program.

Which of the following tasks would require an

intermediate level of health literacy?

a. Identify what is permissible to drink before a medical test,

based on a short set of instructions

b. Explain why it is difficult for people to know if they have a

chronic medical condition, based on information in a one

page article

c. Identify three substances that may interact with an OTC drug

to cause a side effect, using information on the OTC drug

label.

d. Calculate an employee’s share of health insurance costs for

a year, using a table that shows how the employee’s monthly

cost varies depending on income and family size.

7 7

At what reading level are

most medication labels and

guides written?

a. 5th grade

b. 8th grade

c. 11th grade

d. College level

8 8

Which of the following

statements is true?

a. All pharmacy patients should be asked to complete

a health literacy assessment before speaking with a

pharmacist

b. The “teach back” method is designed to assist

patients with visual learning styles

c. Socioeconomic status is directly and consistently

correlated with medication adherence

d. Poor adherence to recommended self care is

suggestive of limited health literacy

9 9

Which of the following practical patient-level

interventions can be used to help ensure literacy-

sensitive communication?

a. Teach to goal by confirming patient

understanding using the teach-back

method.

b. Reinforce verbal communication with visual

information.

c. Ask patients if they have any questions.

d. Both (a.) and (b.) are correct.

10 10

All of the following are considered literacy-

sensitive communication techniques you can use

with patients EXCEPT:

a. Emphasizing a minimum of 5-7 key points.

b. Using the “teach back” or “show me”

method.

c. Using lay language instead of medical terms.

d. Encouraging questions using an open-ended

approach.

11 11

Health Literacy is..

“…the constellation of skills, including the ability to perform basic reading and numerical tasks required to function in the health care environment.”

Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, AMA, 1999

“…the ability to understand and use health-related printed information in daily activities at home, at work, and in the community to achieve one's goals and to develop one's knowledge and potential”

National Assessment of Adult Literacy, 2006

12 12

Components of Health Literacy

Cultural Knowledge

Conceptual Knowledge

Listening Skills

Speaking Skills

Writing Skills

Reading Skills

Numeracy Skills

13 13

Demographic Correlates of

Health Literacy

Health Literacy

Age

Minority Race/ Ethnicity

Higher Socioeconomic

Status

Education

English as a second

language

The Health Literacy of America’s Adults.

Results from the 2003 National Assessment of Adult Literacy. 2006.

http://nces.ed.gov/pubs2006/2006483.pdf

14 14

Conceptually Speaking

• Oral and print literacy mediate the individual

capacity (competence and prior knowledge)

to translate health information into new

knowledge, attitudes, self-efficacy, behavior

change and improved health outcomes

• Complexity and difficulty of written and

spoken messages, culture/norms, patient

background, and other barriers to change

influence this process

1. Baker, D. W. (2006). The meaning and the measure of health literacy. J Gen Intern Med. 2006;

21:878-883.

2. Paasche-Orlow MK,Wolf MS. Am J Health Behav. 2007; 31:s19-s26.

15 15

Conceptual Framework of Health Literacy

HEALTH-RELATED

PRINT LITERACY Ability to understand

written health information

HEALTH-RELATED

ORAL LITERACY Ability to orally

communicate about health

Reading

Fluency

Prose

Quantitative

Document

Complexity and

Difficulty of

Spoken

Messages

New Knowledge,

Positive Attitudes

Greater Self-

Efficacy,

Behavior Change

Improved

Health

Outcomes

Complexity and

Difficulty of

Print Messages

Other Factors:

Culture and Norms

Barriers to change

INDIVIDUAL

CAPACITY

From: Baker, D. W. (2006). The meaning and the measure of health literacy. J Gen Intern Med, 21, 878-

883.

Prior Knowledge

Vocabulary

Conceptual

knowledge of health

and healthcare

16 16

Skills vs. Demands

Skills Demands

17 17

Research Has Demonstrated the

Following Consequences Associated

with Low Health Literacy

Poor self-reported health status

Decreased disease understanding

Excess utilization of institutional medical care

Decreased use of preventive health services

Inefficient mix of health utilization and costs

Nielson-Bohlman, L., Panzer, A. M., & Kindig, D. A. (Editors). Health literacy: a

prescription to end confusion. 2004. Washington, DC.: National Academies Press.

18 18

Pharmacy Relevant –

Health Literacy Tasks

Below Basic

• Identify what is permissible to drink before a medical test, based on a short set of instructions

Basic

• Explain why it is difficult for people to know if they have chronic medical condition, based on information in a one page article about the condition

Intermediate

• Identify three substances that may interact with an over-the-counter (OTC) drug to cause a side effect, using the OTC label

• Determine the timing of a prescription drug with respect to eating given the information on a prescription label

Proficient

• Calculate an employee’s share of health insurance costs for a year, using a table that shows how the employee’s monthly cost varies depending on income and family size

Literacy Proficiency Level

The Health Literacy of America’s Adults.

Results from the 2003 National Assessment of Adult Literacy. 2006.

http://nces.ed.gov/pubs2006/2006483.pdf

19 19

The Health Literacy Problem

14%

22%

53%

12%

Health Literacy Proficiency

Below Basic

Basic

Intermediate

Proficient

The Health Literacy of America’s Adults.

Results from the 2003 National Assessment of Adult Literacy. 2006.

http://nces.ed.gov/pubs2006/2006483.pdf

20 20

Recognized Priority Populations

• Racial/Ethnic Minorities

• Low Income Groups

• Women

• Age <18 years

• Age ≥ 65 years

• Residents of rural areas

• Individuals with disabilities or special health care

needs

USDHS. 2009 National Healthcare Disparities Report 2009. AHRQ Publication No. 10-0004.

March 2010. www.ahrq.gov/qual/qrdr09.htm

21 21

IOM, 2004: Health Literacy… “is fundamental to quality care…” Relates to 3 of the 6 aims in IOM Quality Chasm Report:

• Safety • Patient-centered care • Equitable treatment

22 22

The National Action Plan to

Improve Health Literacy

• Develop and disseminate health and safety

information that is accurate, accessible, and

actionable.

• Promote changes in the healthcare system that

improve health information, communication, informed

decision-making, and access to health services.

• Build partnerships, develop guidance, and change

policies.

• Increase the dissemination and use of evidence-

based health literacy practices and interventions.

http://www.health.gov/communication/HLActionPlan/pdf/Health_Literacy_Action_Plan.pdf

23 23

The National Action Plan to

Improve Health Literacy

• Incorporate accurate, standards-based, and developmentally appropriate health and science information and curricula in child care and education through the university level.

• Support and expand local efforts to provide adult

education, English language instruction, and culturally and linguistically appropriate health information services in the community.

• Increase basic research and the development,

implementation, and evaluation of practices and interventions to improve health literacy.

http://www.health.gov/communication/HLActionPlan/pdf/Health_Literacy_Action_Plan.pdf

24 24

Medication Adherence

• In general, “…the extent to which patients take

medications as prescribed by their health care

providers.”

• Defined, measured, and characterized in a variety of

ways

• Integral intermediate step for optimizing health care

outcomes

Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353:487-97.

25 25

Medication Adherence

“Race, sex, and socioeconomic status

have not been consistently associated

with levels of adherence.”

Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353:487-97.

26 26

Medication Adherence

• Factors affecting medication adherence and

persistence have been summarized in four

categories:

Patient Demographics

Psychosocial and behavioral characteristics

Characteristics of the medication regimen

Interface with the health care system

Kreuger KP, Felkey BG, Berger BA. Improving adherence and persistence: a review and assessment of

interventions and description of steps toward a national adherence initiative. J Am Pharm Assoc.

2003;43:668-679.

27 27

Predictors of Poor Medication

Adherence

• Psychological problems (e.g., depression)

• Cognitive impairment

• Asymptomatic disease

• Inadequate follow-up/discharge planning

• Medication side effects

• Patient’s lack of belief in benefit of treatment

• Patient’s lack of insight into the illness

• Poor provider-patient relationship

• Presence of barriers to care or medications

• Missed appointments

• Complexity of treatment

• Cost of medication

Osterberg L, Blaschke T. Adherence to medication.

N Engl J Med. 2005;353:487-97.

28 28

Why is health literacy important

to medication adherence?

• Adherence to medical instructions requires verbal, written and numeric information to manage prescribed treatment(s)

• Optimal adherence requires a patient to…

Read/Listen

Comprehend

Act

• Adherence may be influenced by patient demographic and psychosocial/behavioral characteristics, complexity of treatment regimen and/or health-system interface

• Failure to understand the healthcare provider instructions undermines the integrity of successful adherence to medical instructions

29 29

Health Literacy and

Medication Adherence

• When studied, the relationship between health

literacy and medication adherence is not so clear1

Studies are limited

Measurements vary

• Example2

Those with inadequate health literacy, of African-American

race, and with a grade school education demonstrated

significantly higher odds of nonadherence in bivariate

analyses.

Only African-American race was significant after

considering health literacy, age, race, sex, education and

regimen complexity in multivariable models.

1. Keller DL, Wright J, Pace HA. Impact of health literacy on health outcomes in ambulatory care

patients: a systematic review. Ann Pharmacother. 2008; 42: 1272-1281.

2. Gazmararian JA, Kripalani S, Miller, MJ, et al. Factors associated with medication refill adherence in

cardiovascular-related diseases. J Gen Intern Med. 2006; 21:1215-21.

Where are we falling short?

NOTE: This session involved audience participation and you may not be able to hear all the audience responses.

31 31

Health Literacy and Medication

Management Pharmacy preparedness

Few pharmacies make an effort to identify patients at risk

for low health literacy

Verbal counseling and written information are commonly cited literacy interventions

Although print materials are commonly used, only a minority of physicians, pharmacists and nurses surveyed used key literacy interventions such as

Teach Back

Underlining key points in pamphlets

Telephone follow-up to assess understanding

1. Praska JL, Kripalani S, Seright AL, Jacobson TA. Identifying and assisting low-literacy patients with medication use: a survey of

community pharmacies. Ann Pharmacother. 2005;39:1441-5.

2. Schwartzberg JG, Cowett A, VanGeest J, Wolf MS. Communication techniques for patients with low

health literacy: a survey of physicians, nurses, and pharmacists. Am J Health Behav. 2007;31:S96-104.

32 32

Health Literacy and

Medication Management

Medication labels and guides Written medication information is commonly distributed,

prepared at too high of a reading level (11 to 12th grade), and

often not read by patients

Prescription labels lack standardization and emphasize

information more relevant to the pharmacist than the patient

Auxiliary labels are confusing and are difficult to interpret

Patients can often restate the instructions but cannot

demonstrate correct use of the medication

1. Raynor DK, Blenkinsopp A, Knapp P, et al. A systematic review of quantitative and qualitative research on the role and

effectiveness of written information available to patients about individual medicines. Health Technol Assess 2007;11:1-160.

2. Shrank WH, Avorn J. Educating patients about their medications: the potential and limitations of written drug information. Health

Aff. 2007; 26(3): 731–740.

3. Steering Committee for the Collaborative Development of a Long-Range Action Plan for the Provision of Useful Prescription

Medicine Information. Action plan for the provision of useful prescription medicine information. Unpublished report presented to

The Honorable Donna E. Shalala, Secretary of the Department of Health and Human Services. Vol 1996.

4. Svarstad BL, Mount JK, Tabak ER. Expert and consumer evaluation of patient medication leaflets provided in U.S. pharmacies. J

Am Pharm Assoc 2005;45:443-51.

5. Davis TC, Wolf MS, Bass PF 3rd, Thompson JA, Tilson HH, Neuberger M, Parker RM. Literacy and misunderstanding prescription

drug labels. Ann Intern Med. 2006;145:887-94.

6. Wolf MS, Davis TC, Shrank W, Rapp DN, Bass PF, Connor UM, et al. To err is human: patient misinterpretations

of prescription drug label instructions. Patient Educ Couns. 2007; 67:293-300.

33 33

Health Literacy and

Medication Management

Verbal communication

Healthy People 2010 reported in 1998

14% of patients received oral counseling from

pharmacists

24% of patients received counseling from their prescriber

Shame associated with limited health literacy may preclude

patient inquiry1

1. Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shame and health

literacy: the unspoken connection. Patient Educ Couns. 1996;27:33-9.

34 34

Health Literacy and Medication

Management

Environmental barriers

Many pharmacy settings do not invite patient questions

Pharmacists are often inaccessible and not easy to

identify

Signing forms without explanation does not invite

dialogue

High prescription volume limits patient-pharmacist

interaction

35 35

Disconnect Between Pharmacist and

Patient Perceptions and Expectations

for Literacy Sensitive Communication

• Differences may exist among pharmacist, patient and

independent auditor assessments of literacy-sensitive written

and oral literacy communication practices in community

pharmacy settings.1

• While the use of literacy-sensitive communication practices

by pharmacists is modest (as reported by patients), patient

expectations for these practices is very low.2

1. O’Neal KS, Crosby KM, Miller MJ, Murray KA, Condren M. Assessing Health Literacy Practices in a

Community Pharmacy Environment: Experiences with the Agency for Healthcare Research and Quality

Pharmacy Health Literacy Assessment Tool. AJHP. Under Review.

2. Collum JL, Marcy TR, Stevens EL, Burns CF, Miller MJ. .Exploring patient expectations for pharmacist-

provided literacy-sensitive communication. Work in progress.

What can we do? NOTE: This presentation involved audience participation and you may not

always hear the audience responses.

37 37

Useful Health Literacy Practices

• The Commonwealth Fund Study

– Team effort

– Standardized communication tools

– Plain language, face-to-face communication,

pictorials, and educational materials

– Patient-provider partnership to achieve goals

– Organizational commitment to health literacy

http://www.commonwealthfund.org/usr_doc/Barrett_hltliteracypracticespr

imarycaresettingsexamplesfield_1093.pdf?section=4039

38 38

Strategies for Addressing

Health Literacy Issues

Assess your organization

Review verbal and written communication methods

for plain language

Train staff

Implement recognized literacy sensitive programs

Evaluate progress and impact

39 39

A Starting Point For Help

• AHRQ Health Literacy and Cultural

Competency Webpage

http://www.ahrq.gov/browse/hlitix.htm

• AHRQ Pharmacy Health Literacy Center

http://www.ahrq.gov/pharmhealthlit/

• Health Literacy Universal Precautions Toolkit

http://www.ahrq.gov/qual/literacy/

40 40

Assess Your Organization

41 41

How do I identify patients

with limited health literacy?

• Testing is a controversial topic and not

recommended

• Behaviors Suggestive of limited health literacy

– Inability to keep appointments

– Making excuses (“I forgot my glasses”)

– Non-adherence to medications

– Poor adherence to recommended self-care management

activities (e.g. glucose monitoring, exercise, smoking

– Postponing making decisions

• Adopt a universal precautions approach

42 42

Medicine Lists and Pill Cards

• AHRQ Pill Card

• APhA – My Medication Record

• ASHP – My Medicine List

• Patients can create their own lists

• Medication Reminder Calendars

43 43

Simple Steps for Practice

• Assess patient’s baseline understanding before

providing extensive information

• Speak slowly

• Use lay language instead of medical jargon

• Emphasize 1 to 3 key points

• Encourage questions using an open-ended questions

approach

44 44

Simple Steps for Practice

• Use teach back method in oral communication so

patient can demonstrate understanding

• Printed information should reinforce, not replace oral

communication

• Printed materials should be easy to read format

Simple sentences in bulleted format

Written at ≤6th grade reading level

Highlight or circle key information

Supplemented with relevant visual information

45 45

Create A Culture of Communication

• Ask Me 3 Program1

• Promotes the use of 3 questions to be used by

patients, answered by providers, and encouraged

by health systems

– What is main problem?

– What do I need to do?

– Why is it important for me to do this?

• Promotes tips for clear health communication

– Bring a friend or family member to help

– Make a list of health concerns to discuss with your

provider

– Make a list of current medications

– Ask your pharmacist when you have questions about your

medications

http://www.npsfstore.com/categories/Ask-Me-3-Products/

46 46

• Regulatory Level Oversight agencies must recognize that providers are key in facilitating

communication efforts and reward appropriately

• Health System / Provider Level Create a culture of communication

Share interprofessional responsibility among providers

Use available tools (AHRQ, Ask Me 3, etc.)

• Research Funding

Increase evaluation efforts and their scientific rigor

• Professional Education Emphasize communication training throughout the professional curricula

and post-graduate training and development programs

• Community Level Empower patients through public libraries, senior centers, etc.

Policy Considerations

47 47

Assessing Organizational Literacy

Sensitivity and Friendliness

Consider the following:

What is the organization’s philosophy and mission with respect to cultural competence, language access, and health literacy?

Are policies and procedures in place to accommodate patients with low health literacy or low English proficiency? What are they?

Are written materials in a language and level that your patients can understand?

What training is available to all staff?

What does your organization do well and where are improvements needed?

NOTE: This presentation involved audience participation. You may hear periods of silence while the audience is working in small groups. You may not be able to hear all audience responses.

48 48

Assessing Health Literacy

Current Medications:

ASA 325 mg daily

Diltiazem 240 mg daily

Lipitor 40 mg at bedtime

Coreg 6.25 mg BID

Lotensin 20 mg BID

Lasix 40 mg daily

Trazadone 100 mg at bedtime

Advair 250/50 2 puffs BID

Albuterol 1-2 puffs QID as

needed

TF is a 45 yo with the following medical conditions:

Hypertension, Hyperlipidemia, CHF, COPD, Alcohol

Dependence, Smoker, and Insomnia

Social History:

Employment: Stage Hand but

currently unemployed and

disabled

Education: High school

Marital Status: Divorced with 2

grown children

Race/Ethnicity: Caucasian

49 49

Assessing Health Literacy

• What risk factors make TF most likely to have low

health literacy skills?

• What techniques or tools would you use to assess

TF’s level of health literacy? Discuss the pros and

cons of using the tool or tools you have chosen.

NOTE: This presentation involved audience participation. You may hear periods

of silence while the audience is working in small groups. You may not be able to

hear all audience responses.

50 50

Teaching a patient with low health

literacy skills

Current Medications: ASA 81 mg daily

Atenolol 100 mg daily

Benazepril 40 mg daily

Norvasc 10 mg daily

Multivitamin 1 tablet daily

Tylenol Extra-Strength

1 tablet QID prn pain

PH is a 58 yo with the following medical

conditions:

Hypertension, and Insomnia

Social History: Employment: Line cook at a local

diner

Education: High school education

and some college

Marital Status: Married with two

adult children

Race/Ethnicity: African American

51 51

Teaching a patient with low health

literacy skills

• You’ve assessed that PH has low health literacy skills.

• PH admits that she has trouble remembering if she has

taken her medications.

• What strategies would you use to counsel PH on taking

her medicines as prescribed?

• What tools would you recommend that PH use to assist

her in taking her medications?

NOTE: This presentation involved audience participation. You may hear periods of

silence while the audience is working in small groups. You may not be able to hear

all audience responses.

52 52

Assessing Medication Adherence

Current Medications:

ASA 81 mg daily

Calcium Carbonate 500 mg

w/Vit D 200 units 2 tabs daily

Lovastatin 20 mg at bedtime

Fosamax 70 mg weekly

Atenolol 25 mg daily

Multivitamin 1 tablet daily

Ditropan XL 5 mg daily

Advair 250-50 1 puff BID

Albuterol 2 puffs prn

wheezing

DT is a 68 yo with the following medical conditions:

Hypertension, Hyperlipidemia, Osteoporosis,

Incontinence, and Asthma

Social History:

Employment: Unemployed

Education: High school

Language: English is her

second language

Marital Status: Married with 3

grown children

Race/Ethnicity: Mexican

53 53

Assessing medication adherence in a

patient with low health literacy skills

• You’ve assessed that DT has low health literacy skills.

• DT assures you that she takes her medicines every day.

• What questions would you ask DT to assess medication adherence?

• What strategies would you recommend that DT use to assist her in being adherent with her medications?

NOTE: This presentation involved audience participation. You may hear periods of silence while the audience is working in small groups. You may not be able to hear all audience responses.

54 54

Which of the following tasks

would require an intermediate

level of health literacy?

a. Identify what is permissible to drink before a medical

test, based on a short set of instructions

b. Explain why it is difficult for people to know if they have

a chronic medical condition, based on information in a

one page article

c. Identify three substances that may interact with an

OTC drug to cause a side effect, using information on

an OTC drug label.

d. Calculate an employee’s share of health insurance

costs for a year, using a table that shows how the

employee’s monthly cost varies depending on income

and family size.

55 55

At what reading level are

most medication labels and

guides written?

a. 5th grade

b. 8th grade

c. 11th grade

d. College level

56 56

Which of the following

statements is true?

a. All pharmacy patients should be asked to complete

a health literacy assessment before speaking with a

pharmacist

b. The “teach back” method is designed to assist

patients with visual learning styles

c. Socioeconomic status is directly and consistently

correlated with medication adherence

d. Poor adherence to recommended self care is

suggestive of limited health literacy

57 57

Which of the following practical patient-level

interventions can be used to help ensure literacy-

sensitive communication?

a. Teach to goal by confirming patient

understanding using the teach-back method.

b. Reinforce verbal communication with visual

information.

c. Ask patients if they have any questions.

d. Both (a.) and (b.) are correct.

58 58

All of the following are considered literacy-

sensitive communication techniques you can use

with patients EXCEPT:

a. Emphasizing a minimum of 5-7 key points.

b. Using the “teach back” or “show me” method.

c. Using lay language instead of medical terms.

d. Encouraging questions using an open-ended

approach.