Is Our Pharmacy Meeting Patients' Needs? (continued)

Introduction

Why Conduct a Pharmacy Health Literacy Assessment?

Health literacy is an important factor in an individual's ability to perform various health-related tasks. These include filling a prescription and taking medications correctly, reading and being able to act on information from a disease prevention brochure, filling out forms, and making decisions about health insurance. In its 2001 report Crossing the Quality Chasm and its 2004 report Health Literacy: A Prescription to End Confusion, the Institute of Medicine indicated that health care providers must redesign the system of health care delivery in order to meet the needs of low-literate individuals.^2,3

Results from the 2003 National Assessment of Adult Literacy indicate that many Americans have difficulty understanding and acting upon health information.⁴

• 14 percent of adults (30 million people) have below basic health literacy—meaning that they are either non-literate in English or can perform no more than the most simple and concrete health literacy tasks, such as circling the date of a medical appointment on an appointment slip.
• An additional 22 percent (47 million people) have basic health literacy—indicating that they can perform only simple health literacy activities, such as locating one piece of information in a short document.

While about half (53 percent) of adults have intermediate health literacy—for example, determining a healthy weight for a person on a body mass index chart— just 12 percent of adults have proficient health literacy. In other words, only about one out of ten adults may have the skills needed to manage their health and prevent disease.

Some adults are more likely to have limited health literacy than others, including those who:

• Are Hispanic, Black, and American Indian/Alaskan Native.
• Have lower incomes.
• Are in poorer health.
• Have limited English proficiency.
• Are age 65 and older.

A pharmacy health literacy assessment is an important first step for quality improvement in organizations that serve individuals with limited health literacy.⁵

A pharmacy health literacy assessment:

• Raises pharmacy staff awareness of health literacy issues.
• Detects barriers that may prevent individuals with limited literacy skills from accessing, comprehending, and taking advantage of the health information and services provided by the organization.
• Identifies opportunities for improvement.

The assessment may also provide a baseline assessment prior to implementing an intervention. A followup assessment will allow evaluation of the intervention's impact on accessibility of the organization to individuals with limited health literacy.

Preparing to Conduct a Pharmacy Health Literacy Assessment

A pharmacy health literacy assessment measures how well an organization is serving patients with limited health literacy. To ensure that the assessment produces valid and useful results, you will want to do the following before beginning the assessment:

• Obtain the support of the organization's staff, particularly leadership. This assessment involves significant staff participation, and it will not be successful without the commitment of the staff.
• Consider the makeup of the staff and patient populations to ensure that all groups are represented.
• Think about the health literacy issues relevant to the organization, and consider adding or deleting items in the assessment as appropriate.

About This Assessment Tool

This Pharmacy Health Literacy Assessment Tool was designed to capture three critical perspectives—objective auditors, pharmacy staff, and patients. The assessment is divided into three parts:

• Part I: A Pharmacy Assessment Tour to be completed by objective, trained auditors.
• Part II: A survey to be completed by pharmacy staff.
• Part III: A guide for focus groups with pharmacy patients.

The three parts are complementary and are designed to form a comprehensive assessment. Organizations unable to tackle the comprehensive assessment will still find it useful to undertake one or two of the three parts. Appendix I depicts a flow chart of the assessment process.

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Part I: Assessment Tour of the Pharmacy

About the Pharmacy Assessment Tour

Objective auditors should observe both the physical environment of the pharmacy and staff interactions with patients. Auditors identify barriers that inhibit clear communication of health information to patients with limited literacy skills. Each Pharmacy Assessment Tour will require approximately 20 to 30 minutes to complete.

Auditors rate the pharmacy using the Pharmacy Assessment Tour Guide (Appendix 2), which consists of the following three sections:

• Promotion of Services.
• Print Materials.
• Clear Verbal Communication.

Who Should Conduct the Pharmacy Assessment Tour?

The Pharmacy Assessment Tour Guide should be completed by at least two objective auditors per pharmacy. Although the items in the Pharmacy Assessment Tour Guide are designed to be straightforward and not open to individual interpretation, completion by two or three auditors will provide a check on potential bias. Auditors should:

• Be familiar with the principles of clear health communication.
• Not be pharmacy staff or patients.
• Be able to blend in with patients who use the pharmacy so that pharmacy staff is not aware of when the assessment is being conducted.

When Should Pharmacy Assessment Tours be Conducted?

Assessment tours should be completed during a very busy time in the pharmacy as well as during a less busy time. Pharmacies may also function differently on the weekend than on a weekday. It is important to observe staff-patient communication in these different situations.

Training Auditors

To promote consistent assessment techniques, auditors should be trained together in the use of the Pharmacy Assessment Tour Guide. The trainer should review the instructions below and those in the actual Assessment Tour Guide, and ensure that auditors are clear on how to complete the Pharmacy Assessment Tour.

Instructions for Completing the Pharmacy Assessment Tour Guide

The Pharmacy Assessment Tour Guide consists of 19 questions. Auditors should complete the Guide as thoroughly as possible, using Table 1 to select an appropriate response to each question. Auditors should use the "comments" box at the end of each section to record any additional important observations or information. To assess items 11-16, the auditors will need to obtain any materials that are not readily available to them in the pharmacy (such as prescription information leaflets, warning labels, and bottle labels) from pharmacy staff at the end of the Pharmacy Assessment Tour. Please refer to the full Assessment Tour Guide (Appendix 2) for additional item-specific instructions.

Table 1: Assessment Tour Response Options

Response Option	Significance
1. This is something the pharmacy does not appear to be doing.	Auditor was able to assess the item and found that the statement was not true of the pharmacy.
2. The pharmacy is doing this but could make some improvements.	Auditor found that the item refers to something that the pharmacy was doing moderately well, or was doing in some instances but not others.
3. The pharmacy is doing this well.	Auditor felt that the pharmacy was doing a good job of addressing the aspect of a health literacy-friendly environment that the item refers to.
4. Not applicable (N/A)	The item was not applicable to the location being audited, or the item asks about a material (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 item for another reason. Auditor should indicate why the item could not be assessed in the "Comments" box.

Analyzing Pharmacy Assessment Tour Results

Results of the Pharmacy Assessment Tour can be analyzed using a spreadsheet (e.g., Microsoft Excel) or a statistical software program such as SPSS (SPSS Inc., Chicago, IL) or SAS® software (The SAS System for Windows, SAS Institute, Cary, NC). Table 2 indicates how responses should be entered into the spreadsheet or statistical package.

Table 2: Coding of Responses for Pharmacy Assessment Tour

Coding Pharmacy Assessment Tour Results

Response Option for Items 1-18b	Code
1. This is something that the pharmacy does not appear to be doing.	1
2. The pharmacy is doing this but could make some improvements.	2
3. The pharmacy is doing this well.	3
4. Not applicable (N/A)	Spreadsheet: Leave blank and do not include item in calculations. Statistical software code: 7
5. Blank (No box checked)	Spreadsheet: Leave blank and do not include item in calculations. Statistical software code: 7

Response Option for Items 19a-e	Code
No	0
Yes	1

Spreadsheet. Each item or sub-item should be a separate row, and each auditor should be a separate column, with the last column being for the mean score. Average across the auditors to create a mean score for each item or sub-item. Not applicable or otherwise blank items should not be included in the numerator or denominator of the average.

Statistical software. Create a variable for each item or sub-item. Calculate mean responses for each variable. Responses of "N/A" or otherwise blank items, coded as "7," should be identified as missing or otherwise excluded from analysis when calculating means.

Check for auditor disagreement. Are there items for which auditors chose very different response options? Have a meeting with all of the auditors to discuss any disparate responses. For example, might the fact that auditors visited the pharmacy on different days of the week or times of the day explain differences?

Analyze the auditors' comments. Do any themes emerge from the auditors' comments? These will be useful for identifying issues not addressed by specific items on the Pharmacy Assessment Tour Guide.

Interpreting and Reporting Pharmacy Assessment Tour Results

A lower mean score suggests that the pharmacy does not appear to be doing well on those particular items. A higher mean score suggests that the pharmacy is doing a better job on those items. Table 3 provides an interpretation of the mean scores.

Table 3: Interpretation of Mean Scores for Items on Assessment Tour Guide

Mean Score	Interpretation
Interpretation of Mean Scores for Items 1-18
1.00-1.99	Pharmacy does not appear to be doing this item.
2.00-2.99	Pharmacy could make some improvements on this item.
3.00	Pharmacy is doing well on this item.
Interpretation of Mean Scores for Items 19a-e
0	All auditors answered "No" to the item.
1	All auditors answered "Yes" to the item.
0.01-0.99	Inconsistency among the auditor responses to the item.

A report on the Pharmacy Assessment Tour results should do the following:

• Identify areas of strength and weakness in the pharmacy environment and in staff interactions with patients, as observed by the auditors.
• Indicate if responses within any one section identified any single area as stronger or weaker than other areas (i.e., promotion of services, print materials, or clear verbal communication).
• Provide recommendations for specific improvements based on areas of weakness identified by the Pharmacy Assessment Tour.

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