Is Our Pharmacy Meeting Patients' Needs? A Pharmacy Health .

Is Our Pharmacy MeetingPatients’ Needs? A PharmacyHealth Literacy Assessment ToolUser’s Guide

This user’s guide was produced under contract to the Agency for Healthcare Researchand Quality (AHRQ) under Contract No. 290-00-0011 T07. The AHRQ Task OrderOfficer for this project was Cindy Brach, M.P.P. The Robert Wood Johnson Foundationprovided funding for this guide. The Robert Wood Johnson Foundation Program Officerwas Pamela S. Dickson, M.B.A.The findings and conclusions in this document are those of the authors, who areresponsible for its contents; the findings and conclusions do not necessarily representthe views of AHRQ or the U.S. Department of Health and Human Services, or theRobert Wood Johnson Foundation. Therefore, no statement in this report should beconstrued as an official position of AHRQ or the U.S. Department of Health andHuman Services or the Robert Wood Johnson Foundation.Citation:Jacobson KL, Gazmararian JA, Kripalani S, McMorris KJ, Blake SC, Brach C. Is OurPharmacy Meeting Patients’ Needs? A Pharmacy Health Literacy Assessment ToolUser’s Guide. (Prepared under contract No. 290-00-0011 T07.) AHRQ Publication No.07-0051. Rockville, MD: Agency for Healthcare Research and Quality. October 2007.

Is Our Pharmacy Meeting Patients’ Needs? A PharmacyHealth Literacy Assessment ToolUser’s GuidePrepared for:Agency for Healthcare Research and QualityU.S. Department of Health and Human Services540 Gaither RoadRockville, MD 20850www.ahrq.govContract No. 290-00-0011ByKara L. Jacobson, MPH, CHESJulie A. Gazmararian, PhD, MPHSunil Kripalani, MD, MScKaren J. McMorris, BASarah C. Blake, MACindy Brach, MPPAHRQ Publication No. 07-0051October 2007

Modifying the Tool to Meet Your NeedsThis assessment tool was designed for use in a specific environment—the outpatientpharmacies of large, urban, public hospitals that primarily serve a minority populationwith a high incidence of chronic disease and limited health literacy skills. Userswishing to assess a different type of organization or pharmacy environment may usethis assessment tool as a template and add, omit, and adapt items as appropriate. Thetool may also be used to assess a non-pharmacy environment with more extensiveadaptation of pharmacy-specific items and terms. We encourage you to modify the toolto meet the needs of your organization.AcknowledgementsThe structure of this assessment and many of the individual items were adapted fromLiteracy Alberta’s Literacy Audit Kit,1 a tool created for conducting a general literacyassessment of an organization by staff members. Both the Literacy Alberta assessmenttool and our pharmacy-specific tool may be adapted as needed to assess different typesof organizations.Thanks are due to Rima Rudd (Harvard School of Public Health), Ruth Parker (EmoryUniversity School of Medicine), Dan Cobaugh (ASHP Foundation), and Terry Davis(Louisiana State University Health Sciences Center), who reviewed a draft of thisassessment tool.ii

ContentsIntroduction.1Part I: Assessment Tour of the Pharmacy .3Part II: Survey of Pharmacy Staff .11Part III: Pharmacy Patient Focus Groups.19Part IV: Using Assessment Results .27References.66AppendixesAppendix 1: Conducting a Health Literacy Assessment-Flow Chart .32Appendix 2: Health Literacy Assessment Tour Guide .33Appendix 3: Health Literacy Assessment Survey of Pharmacy Staff .41Appendix 4: Samples Tables and Analyses for Pharmacy Staff Survey.51Appendix 5: Health Literacy Assessment Facilitator’s Guide for PatientFocus Groups .56Appendix 6: Sample Outline for Report of Focus Group Results .65iii

Introduction Why Conduct a PharmacyHealth Literacy Assessment?Health literacy is an important factor inan individual’s ability to perform varioushealth-related tasks. These include fillinga prescription and taking medicationscorrectly, reading and being able to act oninformation from a disease preventionbrochure, filling out forms, and makingdecisions about health insurance. In its2001 report Crossing the Quality Chasmand its 2004 report Health Literacy: APrescription to End Confusion, theInstitute of Medicine indicated that healthcare providers must redesign the systemof health care delivery in order to meetthe needs of low-literate individuals.2, 3Results from the 2003 NationalAssessment of Adult Literacy indicatethat many Americans have difficultyunderstanding and acting upon healthinformation.4 14 percent of adults (30 millionpeople) have below basic healthliteracy—meaning that they are eithernon-literate in English or can performno more than the most simple andconcrete health literacy tasks, such ascircling the date of a medicalappointment on an appointment slip.An additional 22 percent (47 millionpeople) have basic health literacy—indicating that they can perform onlysimple health literacy activities, suchas locating one piece of informationin a short document.While about half (53 percent) of adultshave intermediate health literacy—forexample, determining a healthy weight fora person on a body mass index chart—just 12 percent of adults have proficienthealth literacy. In other words, only aboutone out of ten adults may have the skillsneeded to manage their health and preventdisease.Some adults are more likely to havelimited health literacy than others,including those who: are Hispanic, Black, and AmericanIndian/Alaskan Native, have lower incomes, are in poorer health, have limited English proficiency, and are age 65 and older.A pharmacy health literacy assessment isan important first step for qualityimprovement in organizations that serveindividuals with limited health literacy.51

A pharmacy health literacy assessment: Raises pharmacy staff awareness ofhealth literacy issuesDetects barriers that may preventindividuals with limited literacy skillsfrom accessing, comprehending, andtaking advantage of the healthinformation and services provided bythe organizationIdentifies opportunities forimprovementThe assessment may also provide abaseline assessment prior to implementingan intervention. A followup assessmentwill allow evaluation of the intervention’simpact on accessibility of the organizationto individuals with limited health literacy.Preparing to Conduct aPharmacy Health LiteracyAssessmentA pharmacy health literacy assessmentmeasures how well an organization isserving patients with limited healthliteracy. To ensure that the assessmentproduces valid and useful results, you willwant to do the following before beginningthe assessment: 2Obtain the support of theorganization’s staff, particularlyleadership. This assessment involvessignificant staff participation, and itwill not be successful without thecommitment of the staff. Consider the makeup of the staff andpatient populations to ensure that allgroups are represented. Think about the health literacy issuesrelevant to the organization, andconsider adding or deleting items inthe assessment as appropriate.About This Assessment ToolThis Pharmacy Health LiteracyAssessment Tool was designed to capturethree critical perspectives—objectiveauditors, pharmacy staff, and patients. Theassessment is divided into three parts: Part I: A Pharmacy Assessment Tourto be completed by objective, trainedauditors Part II: A survey to be completed bypharmacy staff Part III: A guide for focus groupswith pharmacy patientsThe three parts are complementary andare designed to form a comprehensiveassessment. Organizations unable totackle the comprehensive assessment willstill find it useful to undertake one or twoof the three parts. Appendix I depicts aflow chart of the assessment process.

Part I:Assessment Tourof the Pharmacy

About the Pharmacy AssessmentTour be familiar with the principles of clearhealth communication,Objective auditors should observe both thephysical environment of the pharmacy andstaff interactions with patients. Auditorsidentify barriers that inhibit clearcommunication of health information topatients with limited literacy skills. EachPharmacy Assessment Tour will requireapproximately 20 to 30 minutes tocomplete. not be pharmacy staff or patients, and be able to blend in with patients whouse the pharmacy so that pharmacystaff is not aware of when theassessment is being conducted.Auditors rate the pharmacy using thePharmacy Assessment Tour Guide(Appendix 2), which consists of thefollowing three sections: Promotion of Services Print Materials Clear Verbal CommunicationWho Should Conduct the PharmacyAssessment Tour?The Pharmacy Assessment Tour Guideshould be completed by at least twoobjective auditors per pharmacy. Althoughthe items in the Pharmacy Assessment TourGuide are designed to be straightforwardand not open to individual interpretation,completion by two or three auditors willprovide a check on potential bias. Auditorsshould:When Should Pharmacy AssessmentTours be Conducted?Assessment tours should be completedduring a very busy time in the pharmacy aswell as during a less busy time. Pharmaciesmay also function differently on theweekend than on a weekday. It is importantto observe staff-patient communication inthese different situations.Training AuditorsTo promote consistent assessmenttechniques, auditors should be trainedtogether in the use of the PharmacyAssessment Tour Guide. The trainer shouldreview the instructions below and those inthe actual Assessment Tour Guide, andensure that auditors are clear on how tocomplete the Pharmacy Assessment Tour.5

Instructions for Completing thePharmacy Assessment Tour GuideThe Pharmacy Assessment Tour Guideconsists of 19 questions. Auditors shouldcomplete the Guide as thoroughly aspossible, using Table 1 below to select anappropriate response to each question.Auditors should use the “comments” boxat the end of each section to record anyadditional important observations orinformation. To assess items 11-16, theauditors will need to obtain any materialsthat are not readily available to them inthe pharmacy (such as prescriptioninformation leaflets, warning labels, andbottle labels) from pharmacy staff at theend of the Pharmacy Assessment Tour.Table 1: Assessment Tour Response Options6Response OptionSignificance1. This is something the pharmacydoes not appear to be doing.Auditor was able to assess the item andfound that the statement was not true ofthe pharmacy.2. The pharmacy is doing this butcould make some improvements.Auditor found that the item refers tosomething that the pharmacy was doingmoderately well, or was doing in someinstances but not others.3. The pharmacy is doing this well.Auditor felt that the pharmacy was doing agood job of addressing the aspect of ahealth literacy-friendly environment thatthe item refers to.4. Not applicable (N/A)The item was not applicable to the locationbeing audited, or the item asks about amaterial (e.g., patient education brochure)that the pharmacy did not appear to have.5. Blank (No box checked)Auditor is unable to assess a certain itemfor another reason. Auditor should indicatewhy the item could not be assessed in the“Comments” box.