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Health Literacy: A Prescription for Understanding
Families and Doctors: People Who Can Read and Understand Health Information Are Healthier
The Journal
October 2003
Health Literacy: A Prescription for Understanding
(The following is a portion of a presentation about health literacy by Angela Cassano, Pharm.D., BCPS, CKHS clinical manager for Pharmacy Services. This presentation was given at the June 20 Crozer-Keystone Conference, "Health Literacy: Communicating Better with our Patients.")
Pharmacists often have a greater opportunity than physicians to detect health literacy in patients. First, we have more frequent access to patients. Many patients see their pharmacist every 30 days instead of on a three-month or six-month basis. No appointments are necessary. Also, the potential to witness a patient having difficulty reading and writing in public is increased.
Some clinicians may hand out literature and discuss the main points in the office, or even have a patient fill out forms in front of the doctor. But often, that doesn't happen and the physician and her staff may be unaware of the patient's reading deficits.
It is not unusual for a pharmacist to be at a cash register and to have the patient tell him or her, "Well, I forgot my glasses. Could you fill out the top half of the check for me?" This happens very frequently, and by law we have to offer patient counseling. We mandate that every patient in every pharmacy sign a slip indicating that they wanted to be counseled or that they didn't want to be counseled. Sometimes signing that piece of paper happens very rapidly; unfortunately, sometime no one catches the fact that the patient doesn't understand. So, for that reason, we do emphasize communication and assessment skills in pharmacy schools more so than did formerly.
I have had more than one patient come in to a clinic where I was working and we just couldn't figure out why their blood pressure wasn't under control. The patient's blood pressure remained high despite very high doses of Clonidine patches. Luckily, because the patient was sitting there in front of me, I asked him to show me where the patch was on his body. And I could see that he had the patch attached to his skin with the plastic covering on, so the medication was not reaching his skin.
On the patch boxes, there is not a whole lot of room to put application instructions. The instructions never say to apply the patch and then put the little plastic covering on top of it. It also does not say to apply a patch only after you have taken the old patch off. This can lead to patients telling you that they have nowhere else to put the patches, which can be life-threatening. We have a responsibility to make sure that we relay such important information to our patients, and not always in written terms, which they may not comprehend.
Another fairly common situation is a patient inserting a suppository with the wrapper attached. Many people giggle at this one because, for obvious reasons, that's not the most comfortable way to insert a suppository. But most people would argue that inserting a suppository is not really comfortable to start with. Other unfortunate cases include women swallowing vaginal suppositories or inserting Fluconazole tablets vaginally. The patient thinks, "That's the source of the problem, so I'll just insert the tablet that way." I could keep going on and on with other examples. Another example is when patients insert tablets up their noses because they had a runny nose. So, it is important for us to catch on to these things and be very explicit in how we talk to our patients.
Prior to becoming a pharmacist, when I was about 15 or 16, I had typical teenage problems with acne. I had been to the beach and gotten a suntan. I thought I was looking pretty good, so I decided I needed to go and get some medication for my acne problem. The doctor put me on the old gold standard, Tetracycline, and I proceeded off to the beach with my grandparents for two weeks. Well, I was so proud of how tan I had gotten until about a week into the vacation when my grandmother grabbed the bottle of medicine and said, "Angela, you are not supposed to be in the sun." I said, 'You're crazy! The bottle of medication is not supposed to be in the sun. It was in the cabinet. The medication is doing fine. I don't know what you are talking about." Luckily, I had color to begin with because people get severe, severe, burns from a Tetracycline and sun combination, so I was very lucky. Unfortunately, other patients have not been as lucky.
Basic prescription instructions found on a bottle can be another problem. For example, a patient may not even understand what the word capsule means. A bottle may say to take two tablets by mouth, twice daily. Well, to most health care providers, that means take two tablets in the morning, and two tablets in the evening. Those instructions can be interpreted any way you can think of, such as "take two tablets in the morning, and take two tablets two hours later." For some medications, that would be fine. But for a lot of our medications, when we prescribe things this way, we really want them spaced out during the day. So, perhaps a better way to word that instruction would be "take two tablets in the morning, take two tablets in the evening."
Sometimes, a very simple fix will work. We have to retrain ourselves to be conscious of the fact that what makes perfect sense to us may not make sense to someone else.
So how can we help?
Here are some strategies that I've tried in the pharmacy or in the clinics, or that co-workers have tried. For obvious reasons, some of these are easier than others. Some of them take less time than others, so it is up to you to pick whatever combination works best for you.
Talk to patients at their level.
Talk to anyone the patient allows you access to.
Don't ever hesitate to not only tell the patient about what it is that they are taking, but ask if there is someone sitting in the room that may be their spouse, their child, even their neighbor. If the patient gives you his permission to discuss his medication, that person that is standing with them when they are putting those four, five or six patches on themselves may advise them they are doing it incorrectly.
Avoid slang terms.
For example, I'm not from this area, and the terms "dinner" and "supper" might not be a big deal in this area. But dinner versus supper confuses people in the South all the time. That's because my definition of dinner is the evening meal. Other people's definition of dinner is lunch and then supper is their evening meal. I learned early in my career not to write on a prescription for a patient to take one tablet with breakfast and one tablet with dinner. The instruction should be to take one tablet with the morning meal and one tablet with the evening meal.
Ask open-ended questions.
If the patient has been on a medication for a long time, then it may be good to ask a patient what the medication is for. Often, the patient will state everything that you want to hear from them--the dose, the times, what it's used for, how long they are going to take it. Again, I am a pharmacist talking to you about this, but these ideas apply to any place along the chain of health care.
Repeat. This certainly deals with the chain of health care. It never hurts the patient to hear about something more than once.
Write full instructions on prescriptions. The "sigs" are there for time savings; they also are historical and are what were used for a long time. Health care workers understand those sigs very well and use them everyday, but it's better and safer to write out a full description on the prescription pad.
Families and Doctors: People Who Can Read and Understand Health Information Are Healthier
About 90 million American adults have trouble understanding such basic health care information as medication instructions, appointment slips, consent papers, insurance forms, and pamphlets.
Studies show that people with poor "health literacy"-the ability to read, understand, and act on health information-are more likely to have serious health problems than those with good health literacy. One recent study found that patients with diabetes who had trouble reading and understanding medical information had poor control of their blood sugar. They were twice as likely to get such serious health problems as eye, kidney, and heart diseases.
Why Is Health Literacy Important?
Only about half of all patients take medications as directed. For many, this is tied to trouble reading prescription labels and other instructions from doctors. Elderly people have more trouble than most, and they typically have more prescriptions. Seniors, nonwhite immigrants, and people with low incomes are more likely to have trouble reading, understanding, and using the health information they receive. Complicated forms and procedures make it even harder for people to understand.
For example, people with diabetes need to monitor their blood sugar, read medication labels, keep many doctors' appointments, and sometimes give themselves insulin shots. A study showed that people with poor health literacy had a harder time sticking to this routine. Researchers think that people with other chronic (ongoing) health problems such as asthma have trouble sticking to their routines, as well.
Poor Health Literacy, More Doctor Visits
Poor health literacy makes people use health care services more, according to the National Academy on Aging. Compared to those with strong health literacy, people with poor health literacy made:
More hospital visits for longer periods
More doctor visits
Much more use of healthcare resources.
Experts estimate that poor health literacy cost $73 billion in extra healthcare costs in 1998.
Families: How to Be "Health Literate"
Your health or that of someone you love depends on you reading and understanding instructions. Don't hesitate to ask for written information you can understand. Be sure to ask for help if you don't understand medication labels, medical forms, or doctor's instructions. The National Institute on Aging offers these tips:
Ask questions.
The more you know, the healthier you can be. If you don't understand a test, word, or medical term your doctor has used or if you want more information about your condition, ask your doctor or nurse to explain in simple terms.
Explain what you've heard or read.
After you get an explanation or instructions, repeat the explanation to you doctor, pharmacist, or nurse in your own words. If there's anything you've missed, he or she can make sure you're on track.
Bring a family member or friend with you to read and listen.
If there's something you forget, chances are your companion will remember.
Don't forget that your kids also will be healthier if they're health literate. Of course, encourage good reading. Also get them started talking to their doctor at each visit, and ask the doctor to explain what she's doing every step of the way.
Health Care Providers: Giving Patients Clear Written Information
The Center for Health Care Strategies (CHCS) recommends that health care information include pictures, diagrams, and video to make the information clear. Pictures help those with poor health literacy understand more easily and could reinforce learning for people with good health literacy.
The CHCS also recommends that you:
Keep educational materials at no higher than a fifth-grade level. Most information is written at a tenth- to twelfth-grade level.
Replace medical terms with common language to describe medical conditions or treatments.
Emphasize what patients should do, rather than medical facts. Make it clear to patients how this problem relates to specific actions they should take.
Information for this article was obtained from HealthVision, a comprehensive source of current health information. Used with permission.