Health Literacy in Pharmacy: Introduction

Slide Deck

Four PowerPoint® slide decks have been created for use in pharmacy courses. Each of the slide decks includes sufficient content for a 50-minute class, and can be used independently or with the other slide decks.

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Health Literacy in Pharmacy: Introduction
Curricular Modules for Pharmacy Faculty

Content adapted from Kripalani and Jacobson (2007)

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ObjectivesSlide 2 Image

  • Introduction to health literacy:
    • Health literacy skills.
    • Health system demands.
  • Consequences of a mismatch.
  • Implications for pharmacy.

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Health Literacy Skills

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Health Literacy: An Interaction

Image: Two text boxes contain the following text respectively:

  • Adults' Skills:

    "The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions". (Healthy People 2010)

  • Our Expectations and System Demands:

    Managing medications, remembering and following spoken and written directions, interpretation.

Two arrows point down from these boxes to an oval captioned "Health Literacy."

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Adults' Skills

A majority of U.S. adults have difficulty using print materials to accomplish everyday tasks such as:

  • Calculate a 15% tip on a bill.
  • Use a bus schedule to determine time of arrival.
  • Use labels to compare and contrast safety ratings on a piece of equipment such as a bicycle helmet.
  • Read an over-the-counter medicine box to determine how much medicine to give a child of a specified weight and age.
  • Determine the point-of-view [bias] in an editorial.

Source: 1) Kirsch, I., Jungeblut A., Jenkins, L. and Kolstad, A. (1993) 'Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey (NALS)', National Center for Education Statistics, US Department of Education Washington, DC.
2) Kutner, M., Greenberg, E. and Baer, J. (2005) 'A First Look at the Literacy of America's Adults in the 21st Century', National Center for Education Statistics, NCES 20062470, Washington, DC.

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Health Literacy in America

Image: A bar graph shows the following literacy data:

  • Proficient: 12%.
  • Intermediate: 53%.
  • Basic: 22%.
  • Below Basic: 14%.

National Assessment of Adult Literacy Survey Results:

Proficient: Define medical term from complex document; calculate share of employee's health insurance costs.

Intermediate: Determine healthy weight from BMI chart; interpret prescription and over-the-counter drug labels.

Basic: Understand simple patient education handout.

Below Basic: Circle date on appointment slip, understand simple pamphlet about pre-test instructions.

*Approximately 45% of high school graduates have limited health literacy.

Source: 1) Kutner et al (2006) 2) Centers for Disease Control and Prevention Health Literacy Training for Public Health Professionals: http://www2a.cdc.gov/TCEOnline/registration/detailpage.asp?res_id=2074 Found in: Kripalani, S. & Jacobson, K. L. (2007). Strategies to Improve Communication Between Staff and Patients: Training Program for Pharmacy Staff. Rockville, MD: Agency for Healthcare Research and Quality.

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High-Risk Groups

The following groups are more likely to have limited literacy skills:

  • Elderly.
  • Minorities.
  • Limited English Proficiency (LEP) patients.
  • Low income.
  • Homeless.
  • Prisoners.
  • Persons with limited education.

Source: Kirsch et al (1993). Found in: Kripalani, Jacobson (2007).

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Functional Literacy of.High-Risk Populations

GroupLow Literacy (%)
All50
Elderly (≥ 65)81
Racial/Ethnic group:
White41
Black77
Hispanic78
Education Level:
0-8 yrs96
9-1281
HS/GED55
Immigrants:
0-8 yrs prior educ91
9+ yrs prior educ71

Source: 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. Found in: Kripalani, Jacobson (2007).

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Our Expectations in Health Care and the System Demands

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We Expect Patients to...

  • Read:
    • Labels & inserts.
    • Names of medicines.
    • Dosage instructions.
    • Read between the lines [e.g., BID, TID, QID].
  • Listen to explanations and directions.
  • Talk to busy professionals:
    • Describe new feelings (e.g., side effects).
    • Present problems.
    • Ask questions.
  • Track experiences:
    • Watch for side effects and seek appropriate help as needed.
    • Take action for missed dose when needed.
  • Calculate:
    • Measure doses.
    • Count pills.
    • Track amount of meds left and refill as necessary.
    • Use clocks and calendars to set time/day.

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Patients' Experiences

  • People commonly hide their difficulty with reading or understanding.
  • Many feel ashamed of poor reading or understanding.
  • People with limited literacy often avoid reading.

Do you know someone who has problems reading or understanding?

What have you observed?

Source: 1) Parikh N, Parker R, Nurss J. Shame and health literacy: the unspoken connection. Patient Education and Counseling 1995;25:109199.
2) Weiss BD. Health Literacy: A Manual for Clinicians. American Medical Association and American Medical Association Foundation; 2003. Found in: Kripalani, Jacobson (2007).

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What Patients are Saying...

Watch the American College of Physicians (ACP) Foundation Health Literacy Video

  • What surprised you about the patients featured in this video?
  • What types of tasks were the patients in this video asked to complete?
  • How could these patients' experiences have been improved?

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Consequences of a Mismatch

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Patient-Level Consequences

  • Poorer health outcomes.
  • Increased hospitalizations.
  • Greater use of emergency care.
  • Missed prescription refills.
  • Difficulty understanding medication instructions and warning labels:
    • Inappropriate dosing or timing of meds.
    • Failure to recognize side effects or drug interactions.

Source: 1) Agency for Healthcare Research and Quality. Health Literacy Interventions and Outcomes: An Updated Systematic Review. March 2011.
2) American Medical Association Foundation. Health Literacy and Patient Safety: Help Patients Understand. August 2007.

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Health Literacy and Medication Understanding

  • Ability to identify their own medications:
    • 12-18 x greater odds of being unable.
  • Understanding of how to take medications:
    • Take med every 6 hours - 52% correct.
    • Take med on empty stomach - 46% correct.
  • Understanding of drug mechanisms and side effects:
    • Warfarin works by thinning blood - 70% correct.
    • Bleeding/bruising most common SE - 49% correct.
  • Misinterpretation of common warning labels:
    • 3-4 x more likely to misinterpret.

Source: 1) 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.
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) Davis T.C., Wolf M.S., Bass P.F. 3rd, Thompson J.A., Tilson H.H., Neuberger M., Parker R.M.. Literacy and misunderstanding prescription drug labels. Annals of Internal Medicine, December 2006. 19;145(12). Found in: Kripalani, Jacobson (2007).

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Misinterpretation of Warning Labels

Image: A chart shows several standard medication warning labels, such as "Take with Food," "Do not chew or crush. Swallow whole," "Do not drink alcoholic beverages when taking this medication," and "For External Use ONLY."

Source: Davis et al (2006). Found in: Kripalani, Jacobson (2007).

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Medication Errors

Image: A photograph shows a collection of medication bottles.

"How would you take this medicine?"
395 primary care patients in 3 states

  • 46% did not understand instructions ≥1 labels.
  • 38% with adequate literacy missed at least 1 label.

Source: Davis et al (2006). Found in: Kripalani, Jacobson (2007)

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Medication Errors (cont'd)

Image: A sample medication bottle is shown with confusing instructions: "Take two tablets by mouth twice daily."

"Show me how many pills you would take in 1 day."

Source: Davis et al (2006).

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Medication Errors (cont'd)

Image: A bar graph shows the following data for rates of understanding by patient literacy level:

Low:

  • Understanding: 70.7%.
  • Demonstration: 34.7%.

Marginal:

  • Understanding: 84.1%.
  • Demonstration: 62.8%.

Adequate:

  • Understanding: 89.4%.
  • Demonstration: 80.2%.

Rates of Correct Understanding vs. Demonstration "Take Two Tablets by Mouth Twice Daily"

Source: Davis et al (2006).

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Societal Consequences

Societal Consequences:

  • Nonadherence:
    • Missed refills.
    • Inappropriate dosing or timing of meds.
    • Failure to recognize side effects or drug interactions.
  • Increased emergency department costs among low health literacy patients.
  • Undermines efforts to increase patient self-management and engagement in care.

Source: 1) American Medical Association Foundation (2007); 2) AHRQ (2011).

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Pharmacy-Level Consequences

Pharmacy-Level Consequences:

  • Impact on customer loyalty/satisfaction.
  • Decreased profits due to missed refills.
  • Liability—NYS settlement for LEP patients.

Source: 1) American Medical Association Foundation (2007) 2) AHRQ (2011).

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References

  • Agency for Healthcare Research and Quality. Health Literacy Interventions and Outcomes: An Updated Systematic Review. March 2011. Available at: http://www.ahrq.gov/clinic/tp/lituptp.htm.
  • American Medical Association Foundation. Health Literacy and Patient Safety: Help Patients Understand. August 2007. Available at: http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf.
  • Centers for Disease Control and Prevention Health Literacy Training for Public Health Professionals: http://www2a.cdc.gov/TCEOnline/registration/detailpage.asp?res_id=2074.
  • Davis T.C., Wolf M.S., Bass P.F. 3rd, Thompson J.A., Tilson H.H., Neuberger M., Parker R.M.. Literacy and misunderstanding prescription drug labels. Annals of Internal Medicine, December 2006. 19;145(12).
  • DeWalt D.A., Callahan L.F., Hawk V.H., Broucksou K.A., Hink A., Rudd R., Brach C. Health Literacy Universal Precautions Toolkit. (Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, under Contract No. HHSA290200710014.) AHRQ Publication No. 10-0046-EF) Rockville, MD. Agency for Healthcare Research and Quality. April 2010.

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References (cont'd)

  • Kirsch, I., Jungeblut A., Jenkins, L. and Kolstad, A. (1993) 'Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey (NALS)', National Center for Education Statistics, U.S. Department of Education, Washington, DC.
  • Kutner, M., Greenberg, E. and Baer, J. (2005) 'A First Look at the Literacy of America's Adults in the 21st Century', National Center for Education Statistics, NCES 2006-2470, Washington, DC.
  • Kripalani, S. & Jacobson, K. L. (2007). Strategies to improve communication between staff and patients: Training program for pharmacy staff. Rockville, MD: Agency for Healthcare Research and Quality.
  • Spector S.L. and Youdelman, M. Analysis of State Pharmacy Laws: Impact of Pharmacy Laws on the Provision of Language Services. National Health Law Program (2010).
  • Warholak T.L., Nau D., (Editors). Quality & Safety in Pharmacy Practice. New York, NY: McGraw-Hill Medical; 2010.
  • Warholak T.L, West D., Holdford D.A. Educating Pharmacy Students and Pharmacists to Improve Quality. Journal of the American Pharmacists Association (2003). 2010 Jul-Aug;50(4):534-8.

Return to Document

Page last reviewed December 2011
Internet Citation: Health Literacy in Pharmacy: Introduction: Slide Deck. December 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/pharmlitqi/slidedeck1/slidedeck1.html