Ask the Pharmacist

Learning  English  and  Pharmacy-­‐related  

Skills  (LEAPS)  in  the  ESL  Classroom:    
A  Pilot  Study  
April  23,  2010  
Allison  Lam,  UCSF  School  of  Pharmacy,  HPM  Pathway  
Chris:na  Lorimer,  SF  State  University  M.A.  TESOL  Program  
Maricel  Santos,  Ed.D.,  SF  State  University  M.A.  TESOL  Program  
R.  William  Soller,  Ph.D.,  UCSF  School  of  Pharmacy,  Center  for  Self  Care  
1  
1. Background  of  study  popula:on  and  health  
concerns  
2.  Collabora:on,  research  goals  
3.  Key  learning  concepts,  materials  
       prepara:on,  implementa:on  
4.  Results,  implica:ons,  next  steps  

2  
2  
 PATIENT   EFFECTIVE   PHARMACIST  
COMMUNICATION  

1  Enhancing  Prescrip:on  Medicine  Adherence:  A  Na:onal  Ac:on  Plan.    Na#onal  Council  on  Pa#ent  Informa#on  and  Educa#on.  August  2007.  Available  online:  

www.talkaboutrx.org   3  
2  Curry  JD.  The  case  for  pharmaceu:cal  care.  In:  A  Prac:cal  Guide  to  Pharmaceu:cal  Care  2nd  ed.  Washington,  DC:  American  Pharmaceu:cal  Associa:on,  2003   3  
 •  In  2008,  24.4  million  in  the  U.S.  with  Limited  English  
Proficiency  (LEP).1  
•  Each  year,  there  are  over  1.2  million  new  immigrants  
in  the  U.S.,  many  of  whom  have  liXle  to  no  English  
language  skills.  2  
•  LEP  pa:ents  are  at  high  risk  of  medica:on  errors  
because  of:  
–  Lack  of  knowledge  and/or  comprehension  of  medica:on  and  
dosing  instruc:ons    
–  Problems  with  medica:on  adherence  3  

1  Migra:on  Policy  Ins:tute.  hXp://www.migra:oninforma:on.org/datahub/countrydata/data.cfm.    

2  Selected  Social  Characteris:cs  in  the  United  States:  2008.  U.S.  Census  Bureau,  2008  American  Community  Survey.    hXp://fac[inder.census.gov.     4  
3  Westberg  SM,  Sorenson  TD.  Pharmacy-­‐related  health  dispari:es  experienced  by  non-­‐English-­‐speaking  pa:ents:  impact  of  pharmaceu:cal  care.    

J  Am  Pharm  Assoc.  2005;  45(1):  48-­‐54.  

 Therapeu7c  Errors  
•  10/100  fold  error  
•  Confusion  about  
formula:on  or  units  of  
measure  
•  Increased  frequency  
•  Adult  dose  
•  Inadvertent  double  dose  
•  Mul:ple  agents  with  
same  ingredients  
1  Severe  injury  or  death  in  young  children  from  therapeu:c  errors:  a  summary  of  238  cases  from  the  American  Associa:on  of  Poison  Control  Centers.  Tzimenatos  L,  Bond  R,  

and  Pediatric  Therapeu:c  Error  Study  Group.  Clinical  Toxicology.  2009(47).  348-­‐354..     5  
2  Crouch  Bl,  Carava:  EM,  Moltz  E.  Tenfold  terapeu:c  dosing  errors  in  young  children  reported  to  U.S.  poison  control  centers.    

Na:onal  Ins:tute  For  Literacy:  Health  Literacy  V45,15.  .  

 Cultural/Linguis7c  Barriers  
•  Treatment  tradi:ons  and  
preferences  
•  Group  s:gma  about  
mental  or  physical  illness  
•  Cultural  hierarchy  
•  Inaccessible  formal  
pharmacology  registers  
•  Abbrevia:ons    
•  Readability  by  design  
1  Severe  injury  or  death  in  young  children  from  therapeu:c  errors:  a  summary  of  238  cases  from  the  American  Associa:on  of  Poison  Control  Centers.  Tzimenatos  L,  Bond  R,  

and  Pediatric  Therapeu:c  Error  Study  Group.  Clinical  Toxicology.  2009(47).  348-­‐354..     6  
2  Crouch  Bl,  Carava:  EM,  Moltz  E.  Tenfold  terapeu:c  dosing  errors  in  young  children  reported  to  U.S.  poison  control  centers.    

Na:onal  Ins:tute  For  Literacy:  Health  Literacy  V45,15.  .  

The  ESL  Classroom  
The  English  as  Second  Language  (ESL)  classroom  is  an  op7mal  site  
ESL  teachers  provide  immigrant  adults  with  a  ‘safe’  space    

•  Opportunity  
Develop  ac:ve  learning  materials  for  the  ESL  classroom  designed  to  
teach  the  skills  needed  for  effec:ve  communica:on  with  a  
pharmacist  and  to  assure  safe  medica:on  use  at  home  

7  
 The  Pharmacist-­‐Patient  Relationship  

LEP  PATIENTS   EFFECTIVE   PHARMACIST  

COMMUNICATION  

↑  Adherence  
↓  Medica7on  Errors  
1  Enhancing  Prescrip:on  Medicine  Adherence:  A  Na:onal  Ac:on  Plan.    Na#onal  Council  on  Pa#ent  Informa#on  and  Educa#on.  August  2007.  Available  online:  

www.talkaboutrx.org   8  
2  Curry  JD.  The  case  for  pharmaceu:cal  care.  In:  A  Prac:cal  Guide  to  Pharmaceu:cal  Care  2nd  ed.  Washington,  DC:  American  Pharmaceu:cal  Associa:on,  2003  
Pharmacists   ESL  teachers  

9  
 Research  Objectives  
1.  Share  knowledge  with  ESL  adult  learners  about  
effec:ve  communica:on  with  community  
pharmacists  when  picking  up  a  new  prescrip:on    
2.  Share  knowledge  with  ESL  adult  learners  about  safe  
medica:on  use  in  the  self-­‐care  sehng  

10  
.    
 Research  Aims  
1.  Develop,  implement  and  assess  ac7ve  learning  
materials  designed  to  simultaneously  improve  health  
literacy  and  English  language  skills.  

2.  Advocate  for  effec7ve  self-­‐care  prac7ces  by  teaching  

important  ques:ons  to  ask  a  pharmacist  and  important  
steps  to  safe  medica:on  use  at  home.  

3.  Strengthen  ESL  adult  learners’  capacity  to  ini:ate  and  

sustain  health-­‐related  conversa:on  and  independently  
carry  out  pharmacy  related  tasks.  

11  
.    
 Key  Learning  Concepts  
•  Three  ques7ons  to  ask  the  pharmacist1  
(1)  What  is  the  medicine  for?  
(2)  How  do  I  take  the  medicine?  
(3)  What  are  the  side  effects  of  the  medicine?  

•  Three  steps  to  safe  medica7on  use  at  home  

(1)  Read  the  medicine  label  
(2)  Follow  direc:ons  on  the  medicine  label  
(3)  Call  the  pharmacist  

1  Indian  Health  Service  (HIS)  Counseling  Model.    

12  
 A  Skills-­‐based  Lesson  Plan  
•   Post-­‐assessment   Evalua7on   •   Pre-­‐assessment  

LEAPS       Schema   •   Share  

•   Board  game   Applica7on  
Ac7va7on   experience  
Lesson  Plan  

•   Key  concepts   Comprehension   Knowledge   •   Key  vocabulary  

13  
Adapted  from  Shrum  J.  L.,  &  Glisan,  E.  (1994).  Reflec#ve  teaching  in  second  language  classrooms.  Cambridge:  Cambridge  University  Press.    
Implementation:  Two  ESL  Classrooms  
City  College  of   Community-­‐
San  Francisco   based  English  
(CCSF)     Tutoring  (CBET)    

San  Francisco   Oakland  

Levels  3/4   Levels  3/4  

Primary   Primary  
language:   language:  
Cantonese   Spanish  

14  
 Pre-­‐Assessment  Results:    
Population  Characteristics  
Pre-­‐Assessment  Item   CCSF  (n  =  11)   CBET  (n  =  7)  
Primary  language   Chinese   Spanish  
Gender   M=4,  F=7   M=1,  F=6  
Mean  Age  (Range)  in  years   46.3  ±  9.2  (29-­‐56)   34.7  ±  8.8  (21-­‐46)  
Years  in  the  U.S.     5.6  ±  3.2   12.1  ±  6.0  
Confidence  in  expressing   2.5  ±  0.7   1.7  ±  0.5  
English  
Confidence  in  knowing  what   3.5  ±  1.1   4.0  ±  1.0  
ques:ons  to  ask  pharmacist  
Filled  Rx  in  last  12  months   8  (72.7%)   6  (85.6%)  
Asked  pharmacist  about  Rx   5  (62.5%)   3  (50.0%)  
Requested  drug  info  in   4  (50.0%)   4  (66.7%)  
primary  language  
15  
*  All  data  compiled  and  analyzed  by  Allison  Lam,  UCSF  
 AT  THE  PHARMACY  
1.  What  is  the  medicine  for?  

Materials:  Board  Game  

2.  How  do  I  take  the  medicine?  
3.  What  are  the  side  effects  of  
the  medicine?  
AT  HOME  
4.  Read  the  label  
5.  Follow  direc:ons  
6.  Call  the  pharmacist  

Applica7on  
16  
 AT  THE  PHARMACY  
1.  What  is  the  medicine  for?  

Materials:  Game  Cards  

2.  How  do  I  take  the  medicine?  
3.  What  are  the  side  effects  of  
the  medicine?  
AT  HOME  
4.  Read  the  label  
5.  Follow  direc7ons  
6.  Call  the  Pharmacist  

17  
 Therapeu7c  Errors   Cultural/Linguis7c  Barriers  
•  10/100  fold  error   •  Treatment  tradi:ons  and  
•  Confusion  about   preferences  
formula:on  or  units  of   •  Group  s:gma  about  
measure   mental  or  physical  illness  
•  Cultural  hierarchy  
•  Increased  frequency  
•  Inaccessible  formal  
•  Adult  dose   pharmacology  registers  
•  Inadvertent  double  dose   •  Abbrevia:ons    
•  Mul:ple  agents  with   •  Readability  by  design  
same  ingredients  
1  Severe  injury  or  death  in  young  children  from  therapeu:c  errors:  a  summary  of  238  cases  from  the  American  Associa:on  of  Poison  Control  Centers.  Tzimenatos  L,  Bond  R,  

and  Pediatric  Therapeu:c  Error  Study  Group.  Clinical  Toxicology.  2009(47).  348-­‐354..     18  
2  Crouch  Bl,  Carava:  EM,  Moltz  E.  Tenfold  terapeu:c  dosing  errors  in  young  children  reported  to  U.S.  poison  control  centers.    

Na:onal  Ins:tute  For  Literacy:  Health  Literacy  V45,15.  .  

 AT  THE  PHARMACY   AT  HOME  
1.  What  is  the  medicine  for?   4.  Read  the  label  

Results:  Knowledge  
2.  How  do  I  take  the  medicine?   5.  Follow  direc:ons  
3.  What  are  the  side  effects  of   6.  Call  the  pharmacist  
the  medicine?  

“At  the  Pharmacy”   “At  Home”    

Overall  Score  
Sub-­‐Score   Sub-­‐Score  
(Total  6  points)  
(Total  3  points)   (Total  3  points)  
Chinese  (n=11)  
Pre   3.73  ±  0.91   1.46  ±  0.69   2.27  ±  0.65  
Post   5.18  ±  0.87   2.36  ±  0.67   2.82  ±  0.41  
P-­‐value   0.009   0.016   0.180  
Spanish  (n=7)  
Pre   3.00  ±  0.58   1.14  ±  0.38   1.86  ±  0.69  
Post   5.29  ±  0.76   2.71  ±  0.49   2.57  ±  0.54  
P-­‐value   <0.001   0.009   0.062  
Combined  (n=18)  
Pre   3.44  ±  0.86   1.33  ±  0.59   2.11  ±  0.68  
Post   5.22  ±  0.81   2.50  ±  0.62   2.72  ±  0.46  
P-­‐value   <0.001   <0.001   0.013  
*P-­‐values  calculated  using  paired  t-­‐tests  for  “Overall”  scores  and  “At  the  Pharmacy”  sub-­‐scores  and  
1-­‐sample  sign  test  for  difference  in  means  for  “At  Home”  sub-­‐scores.  Calcula:ons  were  based  on  95%  
confidence  interval  and  alpha  of  <0.05.  

19  
*  All  data  compiled  and  analyzed  by  Allison  Lam,  UCSF  
 AT  THE  PHARMACY   AT  HOME  
1.  What  is  the  medicine  for?   4.  Read  the  label  

Results:  Knowledge  
2.  How  do  I  take  the  medicine?   5.  Follow  direc:ons  
3.  What  are  the  side  effects  of   6.  Call  the  pharmacist  
the  medicine?  

Overall  Score   P  =  0.000   "At  the  Pharmacy"  Sub-­‐Score   P  =  0.000  

All  6  Key  Concepts   3  Ques7ons  to  Ask  the  Pharmacist  
100%   100%  
90%   90%  
80%   80%   44%  
70%   57%   70%  
Percentage  

Percentage  
60%   60%   83%  
87%  
50%   Correct   50%   Correct  
40%   40%  
30%   Incorrect   30%   Incorrect  
56%  
20%   43%   20%  
10%   10%   17%  
13%  
0%   0%  
Pre   Post   Pre   Post  

"At  Home"  Sub-­‐Score   P  =  0.006   "At  Home"  Sub-­‐Score   P  =  0.018  

3  Steps  for  Safe  Medica7on  Use   1  Ques7on  -­‐  Call  Pharmacist  vs.  Others  
100%   100%  
90%   90%   17%  
80%   80%  
70%   70%  
70%   72%  
Percentage  

Percentage  

60%   60%  
91%   Doctor  
50%   Correct   50%  
40%   40%   83%   Pharmacist  
30%   Incorrect   30%  
Neither  
20%  
30%  
20%   17%  
10%   10%  
0%   9%   0%  
11%  
20  
Pre   Post   Pre   Post  
 Results:  Value  of  Lesson  
Post  Assessment  -­‐  Value  Assessment  of  Lesson  

100%   100%   100%   100%  

100%   Ques7ons  rated  on  a  
90%   83%   5-­‐point  Likert  Scale.    
80%   For  example:  
70%  
60%    Extremely  valuable  
50%  
 Valuable  
40%  
 Don’t  know  
30%  
20%  
17%    Not  so  valuable  
10%    Not  at  all  valuable  
0%  
Valuable  -­‐  English   Valuable  -­‐  Med   Recommend  to   Easy  to  complete   Likely  to  ask  RPh  
Skills   Friend   board  game   Q's  

BoXom  2  Boxes   Don't  know   Top  2  Boxes  

4  of  18  students  correctly  wrote  post-­‐assessment  answers  in  English  

21  
Discussion  

Highly  mo:vated   Defined  and  credible  

research  team   lesson  materials  

Key  Factors  
to  Success  

Enjoyable  lesson   Accomplished  ESL  

ac:vi:es   teachers  

Sustainability  
22  
Discussion  and  Impact  
SUSTAINABILITY  
Possible  Limita7ons   -­‐   Lack  of  funding  
-­‐   Transla:on  of  lesson  materials  
-­‐   Available  ESL  classrooms  

•  Project  LEAPS,  Student  Na:onal  Pharmaceu:cal  

Associa:on  (SNPhA)  
•  Approved  March  2010  

23  
  By  drawing  on  the  
exper:se  of  both  
health  and  ESL  
prac::oners,  we  can  
increase  our  
understanding  of  
immigrant  health  
needs  and  provide  a  
unique  perspec:ve  
on  problem  solving  
not  found  in  single-­‐
discipline  research.  

24  
Acknowledgements  
•  Maricel  Santos,  Ed.D.,  SFSU  TESOL  Research  Preceptor  
•  R.  William  Soller,  Ph.D..  HPM  Research  Preceptor  
•  Dr.  Bruce  Macher  and  Dr.  James  Wiley,  (RIMI)  
•  Research  Infrastructure  in  Minority  Ins:tu:ons  (RIMI)  Project  
•  Na:onal  Ins:tutes  of  Health  (NIH)  
•  Thomas  Kennedy,  CCSF  ESL  English  Teacher  
•  Jeff  McClelland,  ESL  English  Teacher  
•  Sarah  Murrmann,  ESL  English  Teacher  
•  Lara  Kucera,  ESL  English  Teacher  
•  Ellie  Vogt,  HPM  Pathway  Advisor  
•  Jim  Lightwood,  Ph.D.    
•  Philip  Chan,  Pharm.D.  
•  Polly  Chew    
•  Cynthia  Liang,  P2  
•  Stephanie  Marin,  P1  
•  Maria  Rivas,  P1  

25  
26