Slide Presentation by Sunil Kripalani, MD, MSc and Kara L. Jacobson, MPH, CHES
This is a slide presentation on strategies to improve communication between pharmacists and patients. This is the text version of the slide presentation. Select to access the (PowerPoint® File, 380 KB; Plugin Software Help).
Strategies to Improve Communication Between Pharmacists and Patients
Users can enter the name(s) of local presenters here. The slide set was developed by Sunil Kripalani, MD, MSc and Kara L. Jacobson, MPH, CHES.
Training Curriculum for Pharmacy Staff
This curriculum was developed and used by the PILL Study, which stands for Pharmacy Intervention for Limited Literacy. It is a combined effort of the Emory Center on Health Outcomes and Quality Rollins School of Public Health, Emory University and the Grady Memorial Hospital, Atlanta, Georgia. The curriculum was supported with funds from the Agency for Healthcare Research and Quality and the Robert Wood Johnson Foundation.
Participants are to:
- 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.
- Hands-on practice.
Health Literacy: "The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions." (Reference: U.S. Department of Health and Human Services. Healthy People 2010.)
Health Literacy in America: Results from the NAAL
This slide has a bar chart on the left side representing the percentage of people surveyed in each category of health literacy in the 2003 National Assessment of Adult Literacy.
12 percent of people surveyed in the NAAL had proficient health literacy skills–e.g., able to define medical terms from complex documents, able to calculate the share of employee's health insurance costs.
53 percent of people surveyed in the NAAL had intermediate health literacy skills–e.g., could determine a health weight from a BMI chart, could interpret prescription and over-the-counter drug labels.
22 percent of people surveyed in the NAAL had basic health literacy skills–e.g., could understand a simple patient education handout.
14 percent of people surveyed in the NAAL had below basic health literacy skills–e.g., could circle the date on an appointment slip, could understand a simple pamphlet about pre-test instructions.
(Reference: Kutner, et al. 2006)
High Risk Groups
Those with the greatest risk of low health literacy are
- Persons with limited education
(Reference: Kirsch, et al. 1993)
Functional Literacy of High Risk Populations
This slide has a chart representing specific population groups and their respective level of lower literacy (in percent).
||Low Literacy (%)
|Elderly (> 65)
|Racial/Ethnic group: White
|Education level: 0-8 yrs
|Immigrants: 0-8 yrs prior education
|9+ yrs prior education
(Reference: Weiss 2005, adapted from Table 2-1)
This slide introduces activity 2. Describe the health care experiences of low-literacy patients.
Health Care Experiences
This slide includes three health care experiences common to people with low health literacy:
- Low-literacy patients commonly hide their difficulty.
- Many feel ashamed.
- Avoidant behaviors.
Two questions to prompt discussion are listed:
- When do you suspect low literacy?
- Your experiences?
(References: Parikh, et al. 1995; Weiss 2003)
Possible Indicators of Low Health Literacy
This slide lists several signs that a patient may have limited health literacy skills.
- Excuses: "I forgot my glasses."
- Lots of papers folded up in purse/pocket.
- Lack of follow-through with tests/appointments.
- Seldom asks questions.
- Questions are basic in nature.
- Difficulty explaining medical concerns or how to take meds.
(References: Weiss 2003; Katz, et al. 2007)
This slide suggests using the same approach with all patients
- Can't tell by looking.
- Communicate clearly with everyone.
- Confirm understanding with everyone.
This slide introduces activity 3: Discuss health literacy and medication use.
Low Literacy and Medication Use
This slide presents results of studies on potential medication use problems that people with low health literacy can experience.
Lower ability to identify their own medications (12-18 times greater odds of being unable to identify their own medications).
Lower understanding of how to take medications (52 percent correctly understood "Take med every 6 hours"; 46 percent correctly understood "Take med on empty stomach").
Lower understanding of drug mechanisms and side effects (70 percent correctly understood "Warfarin works by thinning blood"; 49 percent correctly understood "Bleeding/bruising is the most common side effect").
Higher misinterpretation of common warning labels (3-4 times more likely to misinterpret).
(References: Kripalani, et al. 2006; Gazmararian, et al. 1999; Fang, et al. 2006; Davis, et al. 2006)
Misinterpretation of Warning Labels
This slide includes 7 common pharmacy warning labels with illustrations and ways that patients have misinterpreted the instructions:
Take with food [Patients thought it meant: Don't take food.]
Do not chew or crush, swallow whole [Patients thought it meant: Chew pill and crush before swallowing. Chew it up so it will dissolve. Don't swallow whole or you might choke.]
You should avoid prolonged or excessive exposure to direct and/or artificial sunlight while taking this medication [Patients thought it meant: Don't leave medicine in the sun.]
Do not drink alcoholic beverages when taking this medication [Patients thought it meant: Don't drink and drive. Don't drink alcohol. It's poison, and it'll kill you.]
Do not take dairy products, antacids, or iron preparations within one hour of this medication [Patients thought it meant: If allergic to dairy, don't take medicine. Don't eat for 1 hour after taking medicine.]
Medication should be taken with plenty of water [Patients thought it meant: Don't take when wet. Don't need water. Don't drink hot water.]
For external use only [Patients thought it meant: Use extreme caution in how you take it. Medicine will make you feel dizzy. Take only if you need it.]
(Reference: Davis, et al. 2006. Adapted from Table 2.)
Health Literacy and Medication Use
This slide lists some research findings from studies of patients with lower literacy skills. These patients had...
Greater difficulty understanding numerical information, (e.g., if your blood test result for warfarin is just right when it is between 2.0 and 3.0, which of the following results would be "just right"?
Lower medication adherence.
Anecdotal reports of greater adverse drug events because of medication mistakes.
Higher health care costs due to increase emergency services and hospitalizations.
(References: Fang, et al. 2006; Gazmararian, et al. 2006; Howard, et al. 2005)
Some Challenges in Trying to Improve Things
This slide includes a list of challenges:
- Increasingly complex health system includes greater self-care requirements, more medications for chronic conditions, formulary and manufacturer changes, and medication reconciliation.
- Most patient instructions are written, so low-literacy patients have trouble understanding.
- Verbal instructions are often complex, delivered rapidly, and easy to forget in stressful situation.
What questions do you have?
This slide invites audience discussion.
This slide introduces activity 4.
Review techniques to improve communication with low-literacy patients.
Recommended Strategies to Improve Communication
- Explain things clearly in plain language.
- Focus on key messages and repeat.
- Use a "teach back" or "show me" technique to check understanding.
- Effectively solicit questions.
- Use patient-friendly educational materials to enhance interaction.
(Reference: Kripalani and Weiss 2006)
Explain Things Clearly in Plain Language
This slide details ways to use plain language.
- Slow down the pace of your speech.
- Use plain, non-medical language; say "blood pressure pill" instead of "antihypertensive." Also, pay attention to patient's own terms and use them back.
- Avoid vague terms; say "Take 1 hour before you eat breakfast" instead of "Take on an empty stomach".
Using Plain Language: What could we say instead of...
This slide gives examples of plain language words to substitute for complex words.
Instead of adverse reaction, say side effect.
Instead of hypoglycemia, say low sugar.
Instead of PRN, say when you need it.
Instead of suppository, say pill that goes in your bottom or behind.
Instead of topical, say on skin.
Focus on Key Messages and Repeat
This slide gives suggestions for delivering key messages:
- Limit information, just focusing on 1-3 key points.
- Develop short explanations for common medical conditions and side effects.
- Discuss specific behaviors rather than general concepts, such as what the patient needs to do.
- Review each point at the end.
Use a "Teach Back" to Check Understanding
This slide has a flow chart showing a circular cycle of using a "teach back" method to make sure a patient understands a message.
On the upper left, the flow chart initiates with a new concept, such as health information, advice, or change in management.
An arrow points down and to the right to a box reading Clinician Explains New concept.
An arrow points clockwise to a box reading Clinician Assesses Patient Recall and Comprehension.
An arrow points clockwise to a box reading Clinician Clarifies and Tailors Explanation.
An arrow points clockwise to a box reading Clinician Reassesses Patient Recall and Comprehension.
An arrow points clockwise to a box reading Patient Recalls and Comprehends.
One last arrow points down and to the left to the word Adherence.
(Reference: Schillinger, et al. 2003)
Teach Back Scripts
This slide gives examples of ways to use "teach back" methods:
- 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?
- Let's review the main side effects of this new medicine. What are the 2 things that I asked you to watch out for?
- Show me how you would use this inhaler.
Effectively Solicit Questions
This slide lists examples of how to solicit questions.
Don't say, "Do you have any questions?" or "Any questions?"
Instead say, "What questions do you have?
This slide lists the features of patient-friendly materials.
They include appropriate content, plain language, layout, and illustrations.
Help me make sure I've explained things clearly so far...
This slide invites feedback from the audience, checking for their understanding of the concepts.
How do you know if a patient has low health literacy?
Name at least 2 techniques to improve communication with low-literacy patients.
Provide an example of teach-back.
What questions do you have?
This slide solicits questions from the audience members.
This slide introduces activity 5: Hands-on practice!
Hands on Practice!
This slide explains that the group will divide into groups of 3 to roleplay scenarios among a pharmacist, a patient, and an observer.
Participants should refer to the handouts for instructions for each role.
After each round, the "observer" will provide feedback to the "pharmacist."
Participants should switch roles after each round. Each person should have a chance to play the pharmacist.
Role Play Discussion
This slide encourages discussion among participants with specific questions:
What was different?
Was it hard?
What did you learn?
This slide summarizes some key points of the presentation, such as:
Adopt Universal Precautions.
Implement Strategies to Improve Communication (for example, use plain language, focus on key messages, and teach back).
What questions do you have?
1. Davis TC, Wolf MS, Bass, PF III, Middlebrooks M, Kennen E, Baker DW, Bennett CL, Durazo-Arvizu R, Bocchini A, Savory S, Parker RM. Low Literacy Impairs Comprehension of Prescription Drug Warning Labels. Journal of General Internal Medicine. 2006;21(8):847-851.
2. Fang MC, Machtinger EL, Wang F, Schillinger D. Health Literacy and Anticoagulation-related Outcomes Among Patients Taking Warfarin. Journal of General Internal Medicine. 2006;21(8):841-846.
3. Freidland RB. Understanding Health Literacy: New Estimates of the Costs of Inadequate Health Literacy. Washington, DC: National Academy on an Aging Society; 1998.
4. Gazmararian JA, Baker DW, Williams MV, Parker RM, Scott TL, Green DC, Fehrenbach SN, Ren J, Koplan JP. Health Literacy Among Medicare Enrollees in a Managed Care Organization. JAMA. 1999;281:545-551.
5. Gazmararian JA, Kripalani S, Miller MJ, Echt KV, Ren J, Rask K. Factors Associated with Medication Refill Adherence in Cardiovascular-related Diseases: A Focus on Health Literacy. Journal of General Internal Medicine. 2006;21(12):1215-C15.
6. Howard DH, Gazmararian J, Parker RM. The Impact of Low Health Literacy on the Medical Costs of Medicare Managed Care Enrollees. The American Journal of Medicine. 2005;118(4):371-377.
7. Katz MG, Jacobson TA, Veledar E, 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. Kirsch I, Jungeblut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, DC: National Center for Education Statistics, US Department of Education; September 1993.
9. 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.
10. Kripalani S, Weiss BD. Teaching About Health Literacy and Clear Communication. Journal of General Internal Medicine. 2006;21(8):888-890.
11.Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006-483). Washington, DC: U.S. Department of Education, National Center for Education Statistics; 2006.
12. National Quality Forum. Safe Practices for Better Healthcare, 2003; Washington, D.C.
13. Parikh N, Parker R, Nurss J. Shame and health literacy: the unspoken connection. Patient Education and Counseling. 1995;25:109-199.
14. Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, Leong-Grotz K; Castro C, Bindman AB. Closing the Loop: Physician Communication With Diabetic Patients Who Have Low Health Literacy. Arch Intern Med. 2003;163:83-90.
15. Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Making Healthcare Safer: A Critical Analysis of Patient Safety Practices. Evidence Report No. 43 from the Agency for Healthcare Research and Quality. AHRQ Publication No. 01-E058; 2001.
16.U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000.
17. 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.
18. Weiss BD. Health Literacy: A Manual for Clinicians. American Medical Association and American Medical Association Foundation; 2003.
Current as of October 2007
Kripalani S, Jacobson, KL Strategies to Improve Communication Between Pharmacists and Patients. Text Version of a Slide Presentation. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/pharmlit/kripalanitxt.htm