Johanna Sierra, BS, PharmD Candidate
Nova Southeastern University
College of Pharmacy
Fort Lauderdale, Florida
Vaiyapuri Subramaniam, PharmD, MS
Associate Chief Consultant
Pharmacy Benefits Management Services
Department of Veterans Affairs
Washington, DC
Clinical Affiliate Professor
Nova Southeastern University
College of Pharmacy
Fort Lauderdale, Florida


Millions of Americans suffer from adverse health outcomes each year because of barriers to medication adherence.1 This national burden of poor medication adherence in the United States is, in part, due to low literacy and reading skills and, more specifically, low health literacy. Poor health literacy is most pronounced among patients with lower socioeconomic status and those with chronic medical conditions, such as type 2 diabetes mellitus and hypertension.2 Schillinger et al compared health literacy levels in type 2 diabetic patients and found that nearly 80% of participants with a high school education or less developed poorly controlled diabetes and complications related to higher rates of nonadherence to medications, medical treatments and misunderstanding of lifestyle modifications.3 While health literacy has been recognized widely as a strong predictor of medication adherence, the health care system continues to have significant gaps in the way health information is written and the patient’s ability to understand and act on it.

Addressing low health literacy can be expected to result in major financial savings in the health care industry,4 and pharmacists are in a key position to have a positive influence in this area. Recognizing that the strategies that work for one patient might not yield results in another, they need to provide personalized care for each patient. As pharmacists interact with patients, they can implement some basic methods for improving communication. They should practice speaking slowly in plain nonmedical language, use familiar terms and integrate the patient’s culture, and limit the amount of information presented to a maximum of 3 key points. Pharmacists should avoid vague or relative terms that leave room for interpretation, and instead should give patients specific percentages for frequencies of adverse events to reinforce how rare some of these can be. Patients need to become familiar with the phrase “common side effects” instead of “adverse events.” It also is necessary to confirm at the point of care that the patient understands specific dosing quantities and times to take each of his or her medications. Although the label may state, for example, “take one tablet three times daily,” it is important to make sure the patient knows he or she actually needs to take the drug at evenly spaced intervals. Thus, a pharmacist could recommend, for example, that the patient take one tablet at 8 am, another at 4 pm, and the last one before bedtime.

Communication Strategies

Patients often need to remember a great deal of information after a visit with their health care provider to use their medications correctly and appropriately manage their chronic diseases. Clear communication strategies help patients become more involved in their care plans, increase positive outcomes, and encourage them to ask questions and be proactive with their health care (Table 1).5 A proven way to assess and reinforce the information you have shared with your patient is to use the “teach-back” method.6 This is a simple verbal tool that will help close a communication gap between the pharmacist and the patient. This repetitive form of communication gives the pharmacist an evaluation of the patient’s recall and understanding while allowing the pharmacist to clarify the points that the patient does not understand or is forgetting.

Table 1. Key Communication Strategies
Strategies Comments
Warm greeting Greet patients with a smile and a welcoming attitude.
Eye contact Make appropriate eye contact throughout the interaction.
Plain, non-medical language Use common words when speaking to patients. Take note of what words they use to describe their illness and use them in your conversation.
Slow down Speak clearly and at a moderate pace.
Limit content Prioritize what needs to be discussed and limit information to 3 to 5 key points.
Repeat key points Be specific and concrete in your conversation and repeat key points.
Graphics Draw pictures, use illustrations, or demonstrate with 3-D model.
Patient participation Encourage patients to ask questions and be involved in the conversation during visits and to be proactive with their health care.
Teach-back Confirm that patients understand what they need to know and do by asking them to re-teach directions.

Using the teach-back method, after explaining a new concept or counseling about a new medication, the pharmacist asks open-ended questions such as “What are you going to do when you get home?” or “I want to be sure that I explained your medication correctly. Can you tell me how you are going to take this medicine?” The pharmacist also can conclude with specific questions such as “We covered a lot today about your diabetes, and I want to make sure that I explained things clearly. So let’s review what we discussed. What are 3 strategies that will help you control your diabetes?” or “What are 2 possible side effects you should be on the lookout for after starting this new medication?” Over time, this tool can help the pharmacist identify explanations and communication strategies that are most commonly understood by patients for future use.

Patient Education Materials

Pharmacists can promote public health by using their knowledge and skills to develop patient education programs on safe and effective medication use. Often, pharmacists supplement their verbal consultation with written information. It is important to make sure that these patient education materials are easy to read and understand. Medication labels and instruction leaflets often are printed in a small-sized type, making them difficult to read, especially for geriatric patients. In addition to having complicated medication regimens, patients, especially the elderly, may commonly have problems resulting from impairments in cognition, comprehension, recall of information on medications, and vision. Improving these educational materials can lead to better medication adherence.

Personalized Health Sheets

To minimize confusion and improve health literacy for patients, pharmacists should help develop personalized written health information sheets targeted to the patient’s gender, age, and illness(es). Various other examples, along with general counseling points to focus on, are listed in Table 2. Pharmacists should not assume that the patient is taking a medication for the most common indication. Instead, approach patients by asking, “What did the doctor tell you this medication was for?” By asking this simple question, not only will the patient be involved immediately in the conversation but will be encouraged by the pharmacist’s open communication to take a more active role in his or her health care. Additionally, the pharmacist will have the information needed to effectively counsel and guide the patient through the prescribed treatment by focusing on the relevant counseling points instead of superfluous information that does not apply because of the patient’s gender, age, or illness(es).

Table 2. Examples of Common Drugs Dispensed for Alternative Indications
Drug Name Common Indications Possible Alternative Indications Relevant Counseling Points
β-Blockers (eg, atenolol, propranolol, nadolol) Angina, hypertension Migraine prophylaxis Warn patients about possible impaired cognition and dizziness due to decreases in BP, but focus counseling on migraine management. Advise patients to keep a migraine journal to identify triggers, keep track of frequency and severity. Contraindications such as asthma, depression, and peripheral vascular disease often limit use (complete medical history needed). Advise patients with diabetes to carefully monitor blood glucose because drugs can mask hypoglycemia.
Tricyclic antidepressants (eg, amitriptyline) Depression Chronic pain, insomnia, migraine prophylaxis Use with caution in patients with heart disease and epilepsy. Possible sedation; recommend bedtime administration and avoidance of concomitant alcohol. Advise patients that symptom improvements may not be seen for a few weeks.
Clonidine Hypertension Attention deficit/​hyperactivity disorder Warn patients about possible dizziness due to decreases in BP. Advise patients against sudden discontinuation of drug because rebound hypertension may occur. Warn patients not to drink alcohol or use other CNS depressants while taking this drug.
Bupropion Depression Smoking cessation Advise patients about possible changes in behavior or appetite. Patients should start treatment 1 week before they stop smoking. Insomnia may be minimized by avoiding bedtime dosing. Recommend smoking cessation classes along with treatment and provide appropriate resources for best outcome.
Sildenafil citrate Erectile dysfunction Pulmonary hypertension Disregard side effects that occur in men (priapism) when counseling female patients. Drug may cause epistaxis, headache, dyspepsia, or possible insomnia. Patients should not take this medication if they are using nitrates.
BP, blood pressure; CNS, central nervous system Based on reference 7.

Medications often are prescribed for a specific health condition and yet can have multiple indications that are not relevant to the patient. Making the information sheets as specific as possible can help minimize confusion. For example, an older man who is prescribed gabapentin for neuropathic pain should not receive information that explains the serious risks of using this medication when pregnant or that the drug is used for the management of epilepsy. This might lead the patient to become alarmed that the pharmacy provided the wrong medication or that the doctor prescribed the incorrect treatment. This is an easy way to lose credibility and the trust that a pharmacist needs to have with patients to foster medication adherence. These sheets also should reflect the fact that people have a preference for picture-based rather than word-based information.

In the United States and around the world, there is compelling evidence that patients are not taking their prescribed medications correctly and that they lack the knowledge to properly navigate the health care system. Health illiteracy is being viewed increasingly as a patient safety concern and a prime source of medication-related errors. The ramifications of failure to follow prescribed medication instructions and to navigate the health management system affect every aspect of health care. According to a study released in June 2013, by the IMS Institute for Healthcare Informatics, nonadherent behaviors have been linked to significantly higher avoidable health care costs, emergency room readmissions, and patient mortality rates.8,9 Pharmacists are in a key position to help promote health literacy and reduce nonadherence to improve patient outcomes and reduce health care costs.

References

  1. Pignone M, DeWalt DA, Sheridan S, Berkman N, Lohr KN. Interventions to improve health outcomes for patients with low literacy: a systematic review. J Gen Intern Med. 2005;20(2):185-192.
  2. Keller DL, Wright J, Pace HA. Impact of health literacy on health outcomes in ambulatory care patients: a systematic review. Ann Pharmacother. 2008;42(9):1272-1281.
  3. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288(4):475-482.
  4. Vernon JA, Trujillo A, Rosenbaum S, DeBuono B. Low health literacy: implications for national health policy. 2003. http://sphhs.gwu.edu/​departments/​healthpolicy/​CHPR/​downloads/​Lowhealth​Literacy​Report​10_4_07.pdf. Accessed August 6, 2013.
  5. DeWalt DA, Callahan LF, Hawk VH, Broucksou KA, Hink A. Health literacy universal precautions toolkit. AHRQ Publication No. 10-0046-EF. www.ahrq.gov/​qual/​literacy/​healthliteracytoolkit.pdf. Accessed July 30, 2013.
  6. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83-90.
  7. Clinical Pharmacology website. http://www.clinicalpharmacology.com. Accessed June 23, 2013.
  8. Howard DH, Sentell T, Gazmararian JA. Impact of health literacy on socioeconomic and racial differences in health in an elderly population. J Gen Intern Med. 2006;21(8):857-861.
  9. Aitken M, Valkova S. Avoidable costs in U.S. healthcare: the $200 billion opportunity from using medicines more responsibly. IMS Institute for Healthcare Informatics; June 2013.

This article was written by the authors in their private capacity, and the opinions expressed are those of the authors and do not represent the views of the Department of Veterans Affairs (VA). No official support or endorsement by the VA is intended or should be inferred.

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