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Ambulatory Care

Identifying and Assisting Low-Literacy Patients with Medication Use: A Survey of Community Pharmacies Jessica L Praska, Sunil Kripalani, Antoinette L Seright, and Terry A Jacobson

BACKGROUND: Nearly one-half of adult Americans have limited functional literacy skills. Low patient literacy is associated with poor medication adherence and health outcomes. However, little is known about how pharmacies address literacy-related needs among patrons. OBJECTIVE: To determine the frequency with which pharmacies identify and provide appropriate assistance to patients with limited literacy skills and provide specific recommendations to help improve pharmacists’ recognition of low health literacy, as well as strategies to improve adherence in this population. METHODS:

Through a telephone-based survey of Atlanta-area pharmacies, we obtained information on (1) whether the pharmacy attempted to identify patients with limited literacy skills, (2) what measures were taken by the pharmacy to optimize the health care of low-literacy patients, especially with regard to medication adherence, and (3) what services the pharmacy offered to improve adherence in general.

RESULTS: The response rate among eligible pharmacies was 96.8% (N = 30). Only 2 (7%) pharmacies reported attempting to identify literacy-related needs among their patrons. One of these facilities provided additional verbal counseling to assist low-literacy patients, and the other pharmacy involved family members, provided verbal counseling, and had patients repeat instructions to confirm comprehension. Most pharmacies reported availability of adherence aids that could help low-literacy patients if such patients were identified and targeted to receive additional assistance. These included verbal and written counseling (offered at 73% of pharmacies), packaging or organizing aids (27%), refill services (17%), and graphic or multimedia aids (13%). CONCLUSIONS: Pharmacies infrequently attempt to identify and assist patients with limited literacy skills. KEY WORDS: adherence, compliance, health literacy.

Ann Pharmacother 2005;39:1441-5. Published Online, 26 Jul 2005, www.theannals.com, DOI 10.1345/aph.1G094

ased on results of the National Adult Literacy Survey,1 the Institute of Medicine recently estimated that nearly half of adult Americans lack the necessary literacy skills to function effectively in today’s healthcare environment.2 Limited literacy skills are common across all demographic groups, although the elderly and individuals from racial and ethnic minorities are disproportionately affected.1 Patients with limited literacy skills not only have difficulty understanding complex consent forms and insurance documents, but may also struggle with basic medication instructions.3,4 For example, in a large study of Medicare

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Author information provided at the end of the text. This work was supported by a grant from the American Heart Association. Dr. Kripalani received support from an Emory Mentored Clinical Research Scholar Award (NIH/NCRR K12 RR017643) and a K23 Mentored Patient-Oriented Research Career Development Award (1 K23 HL077597).

www.theannals.com

managed-care enrollees, 48% of patients with limited literacy skills could not comprehend instructions to take a drug every 6 hours. Over half (54%) could not understand what it meant to take medication on an empty stomach.5 Not surprisingly, low patient literacy is associated with diminished adherence to drug therapy and medication management skills, as well as increased hospitalizations and healthcare costs.6-9 Poor adherence, in turn, has been linked to increased mortality.10,11 Unfortunately, many patients who have trouble reading or understanding health information hide this difficulty due to embarrassment or failure to recognize the limitations of their reading ability. In one study, 91% of adults who were found to have limited literacy skills had never told their supervisor, 68% had not told their spouse, and 19% had never told anyone.12 Thus, it is important for clinicians to be aware of the scope of the problem and offer help when needed, rather than waiting for patients to request assistance.

The Annals of Pharmacotherapy Downloaded from aop.sagepub.com by guest on October 11, 2013



2005 September, Volume 39



1441

JL Praska et al.

The pervasive problem of low patient literacy poses a significant challenge for pharmacists who strive to educate patients on proper medication use and disease management. Yet discussion of literacy skills is uncommon in the pharmacy literature, and little is known about how pharmacists address low literacy.4,13 As of July 11, 2005, no published research has examined pharmacists’ attitudes and practices regarding patient literacy. The purpose of this study was to determine the frequency with which pharmacies identify and provide appropriate assistance to patients with limited literacy skills. We also provide recommendations for how to optimize comprehension and adherence among low-literacy adults. Methods SETTING

In December 2003, we performed a telephone survey of community pharmacies in urban Atlanta, GA. We primarily wished to contact pharmacies that were likely to have a high percentage of patrons with limited literacy skills, postulating that these sites would be the most likely to consider literacy-related issues and offer special assistance to low-literacy consumers. Given the absence of specific data on patient literacy by pharmacy or community, we used census data from 2000 to map areas according to average years of education completed,14 as educational attainment correlates highly with literacy.1 Using addresses from a current local telephone book, we then selected pharmacies from areas with an average educational attainment of