Kayce M. Shealy, PharmD, BCPS, BCACP, CDE
Neyda V. Gilman, MLS
At the end of this case, students will be able to:
- Recognize the role health information literacy plays in health care and how pharmacists literacy skills are necessary to improve patients’ understanding of their health
- Discuss the red flags of limited health literacy
- Identify resources that may be useful for patients with limited health literacy, and why these resources are useful
- Apply the Health Literacy Universal Precautions to a patient case
According to the 2003 National Assessment of Adult Literacy, 36% of US adults aged 16 years or older have health literacy skills at a basic level or below.1 For adults greater than 65 years old, this jumps to 59%, with 29% of those having below basic skills. There are many definitions, but generally health literacy is defined as the “degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”2 Even broader, information literacy is defined as being able to “recognize when information is needed and have the ability to locate, evaluate, and use effectively the needed information.”3 These skills are necessary for patients to be able to understand their health and their current or potential treatments. With poor health literacy, patients are less likely to understand what their health provider is telling them, to see how different aspects of their health tie together, or to know what steps they need to take to keep or improve their health. Additionally, patients with limited health literacy are more likely to experience poorer health outcomes and increased healthcare costs.4-7
In 2009, The Calgary Charter was created by individuals from Canada, the US, and the UK to identify the core principles of health literacy. The definition of health literacy defined by this document includes the important component of the health provider having the information literacy skills necessary to recognize and efficiently solve their own information needs.8 Health literacy is important for pharmacists to be able broaden their knowledge and stay current with health and medical research. An information literate pharmacist is also more aware of his or her patient’s health literacy and has the skills needed to find needed information for the patient, the patient’s prescribing provider, and his or herself as necessary.
Assisting patients with their health literacy and understanding of even one piece of health information can have a beneficial rippling effect, including increasing their comfort and willingness to discuss health questions or concerns with health care providers.9-11 Patients with improved health literacy are also more likely to discuss screening and treatment options, as well as follow recommended treatment procedures and healthy lifestyle habits in order to reduce health risks.
You are a pharmacist in the community setting.
CC: “I need some refills on my meds.”
HPI: Steve tells the pharmacy technician that he needs to refill his “pink round pill, his blue rectangle pill, and his white round pill, and there may be one or two other ones.” While the technicians are submitting the refill requests, you take time to review Steve’s medication profile (see below).
PMH: Depression; hypertension; T2DM
SH: Current tobacco use
|Amlodipine 10 mg PO daily||#90 filled 4 months ago
#90 filled 6 months ago
|Aspirin 81 mg PO daily||#30 filled 28 days ago
#30 filled 3 months ago
|Benazepril 20 mg PO daily||#90 filled 4 months ago
#90 filled 6 months ago
|Bupropion SR 200 mg PO BID||#60 filled 6 months ago
#60 filled 7 months ago
|Glimepiride 4 mg PO daily||#30 filled 28 days ago
#30 filled 3 months ago
|Metformin 1000 mg PO BID||#180 filled 4 months ago
#180 filled 6 months ago
|Sertraline 100 mg PO daily||#30 filled 28 days ago
#30 filled 3 months ago
SDH: Steve completed high school, and currently works at the local post office.
Additional context: Once his prescriptions are ready, you ask Steve if you may take a few minutes to review his medications and other health information. During the counseling, you observe that although Steve has been taking the same medications for the past year, he is unsure as to the exact purpose of each. In addition, he admits to missing some of his follow up appointments with his primary care provider due to various reasons.
1. From this one interaction with Steve, how would you classify his health literacy? Are there any red flags that led you to your conclusion?
Limited or below basic; the patient refers to medications by pill color and shape; gaps in refill dates; unsure of medication purpose.
2. What concepts and/or techniques can be used when communicating with Steve to ensure his complete understanding?
Apply Health Literacy Universal Precautions: Use the teach-back method; use plain language and avoid medical terms (or define medical terms if necessary to use); limit counseling to 3-5 key points and repeat them during the interaction; use the patient’s words; use pictures and/or language at no higher than an 8th grade (5-6th ideal) reading level for written information. Patients who are illiterate may need more visual means or other unique strategies to increase medication knowledge and adherence. Patients who speak English as a second language may also benefit from the use of medical interpreter services to improve communication and understanding.
3. What things should be considered when looking for appropriate health information for patients?
Readability-consider using a tool to determine what grade level the written information is targeting, and select information written at a 5th or 6th grade level; understandability-consider using a tool to assess other factors of the written communication that affect understandability; use numbers in addition to descriptions.
4. What additional resources are available for you to learn more about methods to improve health literacy?
Sign up for alerts and messages from the Institute for Healthcare Advancement’s Health Literacy Discussion List; visit the CDC’s webpage; sign up for free courses through the American Medical Association online; use resources from AHRQ.
Limited health literacy is linked with poor health outcomes.4-7 Patients with limited health literacy are more likely to utilize emergency room services, have more hospitalizations, and are less likely to utilize preventive services like mammography or receive influenza vaccinations compared to their more health literate counterparts. Focused interventions, such as those recommended in the Health Literacy Universal Precautions, have been shown to improve health literacy. In addition, delivery of the interventions by a healthcare professional, like a pharmacist, increases efficacy of the intervention.
While communication skills overlap with health literacy skills, they are not the same thing. It is important to remember that just because a person may have great communication skills, he or she may not necessarily be health literate. In order to effectively communicate about health, especially with a range of levels of health literate individuals, it is necessary to be health literate yourself. Some patients with health literacy issues may benefit by bringing their prescribing providers into the conversation. Prescribing providers and pharmacists who have an understanding and awareness of the importance of health literacy may have improved communication that allows enhanced learning about their patient’s medications and concerns, further benefiting their patients. Positive experiences while communicating with pharmacists could also lead to more open and honest communication and collaboration.
Health literacy not only affects individual patients, but also can affect health-systems due to the costs of increased hospitalizations and healthcare utilization overall. Organizations like Joint Commission recognize the important impact that health literacy plays on patient safety and have encouraged institutions to incorporate policies that facilitate enhanced patient-provider communication.
There are many tools available to formally assess a patient’s health literacy; however, their routine use in practice may be limited due to the time necessary to administer. Quick assessments such as the Single Item Literacy Screener or Newest Vital Sign may be useful for the general population, and assessments such as the Literacy Assessment for Diabetes are more suited for specific patient populations.
Patient Approaches and Opportunities
Health literate pharmacists can positively affect patients. Pharmacists may be able to take more time discussing the patient’s health than other health professionals. They also are able to have their discussions in a different environment than a cold clinical office. By being health literate themselves, and assessing and acknowledging their patients’ level of health literacy, pharmacists can help patients improve understanding of their health information. With this understanding, patients are more likely to take steps to improve their health, including improved drug adherence.12 Pharmacists should apply the Health Literacy Universal Precautions during each patient encounter. Be sure to provide clear communication that incorporates words, numbers, and images that are familiar to the patient or population with whom you are communicating. Strategies that can improve spoken communication include using the patient’s own words; limiting content presented to 3-5 key concepts and repeat; encouraging questions; and incorporating the teach-back method. Utilizing these strategies can help increase patients’ understanding of health information.
Other strategies to help improve health literacy include using clear, basic, and respectful language, a moderate speaking pace, open-ended questions, and easy-to-understand materials including images and diagrams. Other strategies include making and sharing action plans with patients, and directing patients to resources for additional literacy and/or math skill training, as well as community resources as applicable. Example resources include Medline Plus’ Medical Encyclopedia and Word Part appendix, as well as simple articles such as healthywomen.org’s post on health literacy. Regardless of the patient’s health literacy level, having a health literate provider enhances the patient-provider relationship.8
Related chapters of interest:
- More than just diet and exercise: social determinants of health and well-being
- Saying what you mean doesn’t always mean what you say: cross-cultural communication
- Health People 2020, Evidence-Based Resource Summary. https://www.healthypeople.gov/2020/tools-resources/evidence-based-resource/national-action-plan-improve-health-literacy
- Health Literacy Tool Shed. http://healthliteracy.bu.edu/all
- AHRQ Health Literacy Universal Precautions Toolkit. https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html
- Centers for Disease Control and Prevention, What is Health Literacy. https://www.cdc.gov/healthliteracy/learn/index.html
- The Joint Commission, “What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety. https://www.jointcommission.org/assets/1/18/improving_health_literacy.pdf
- Medline Plus Health Literacy. https://medlineplus.gov/healthliteracy.html
- Kountz DS. Strategies for improving low health literacy. Postgraduate medicine. 2009 Sep 1;121(5):171-7.
- Kutner M, Greenburg E, Jin Y, Paulsen C. The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy. NCES 2006-483. National Center for Education Statistics. 2006.
- Health Literacy. NNLM Initiatives Web site. https://nnlm.gov/initiatives/topics/health-literacy. Accessed August 14, 2018.
- American Library Association. Information Literacy Competency Standards for Higher Education. http://www.ala.org/Template.cfm?Section=Home&template=/ContentManagement/ContentDisplay.cfm&ContentID=33553. Published July 20, 2007. Accessed August 14, 2018.
- Cox SR, Liebl MG, McComb MN, et al. Association between health literacy and 30-day healtcare use after hospital discharge in the heart failure population. Res Social Adm Pharm 2017; 13: 754-758. Doi: https://doi.org/10.1016/j.sapharm.2016.09.003
- Schillingeter D, Grumback K, Piette J, et al. Association of health literacy with diabetes outcomes. J Am Med Assoc 2002;31;288(4):475–482.
- Eichler K, Wieser S, Bru¨gger U. The costs of limited health literacy: a systematic review. Int J Public Health 2009;54:313–324. http://dx.doi.org/10.1007/ s00038-009-0058-2.
- McKenna V, Sixsmith J, Barry M. The relevance of context in understanding health literacy skills: Findings from a qualitative study. Health Expectations. 2017;20(5):1049-1060. Available from: CINAHL Complete, Ipswich, MA. Accessed August 14, 2018.
- Coleman C, Kurtz-Rossi S, McKinney J, Pleasant A, Rootman I, Shohet L. Calgary Charter on Health Literacy: Rationale and Core Principles for the Development of Health Literacy Curricula. The Centre for Literacy of Quebec; 2011. https://www.ghdonline.org/uploads/The_Calgary_Charter_on_Health_Literacy.pdf. Accessed August 14, 2018.
- Donald RA, Arays R, Elliott JO, Jordan K. The Effect of an Educational Pamphlet on Patient Knowledge of and Intention to Discuss Screening for Obstructive Sleep Apnea in the Acute Ischemic Stroke Population. Journal of Neuroscience Nursing. 2018;50(3):177-81.
- Cheng Y-L, Shu J-H, Hsu H-C, et al. High health literacy is associated with less obesity and lower Framingham risk score: Sub-study of the VGH-HEALTHCARE trial. PLoS One. 2018;13(3):e0194813.
- Noureldin M, Plake KS, Morrow DG, Tu W, Wu J, Murray MD. Effect of Health Literacy on Drug Adherence in Patients with Heart Failure. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. 2012;32(9):819-826.
- Berkman ND, Sheridan SL, Donahue KE, et al. on behalf of the Agency for Healthcare Research and Quality. Health literacy interventions and outcomes: An updated systematic review. Evidence Report/Technology Assessment No. 199. (Prepared by RTI International–University of North Carolina Evidence-based Practice Center under contract No. 290-2007-10056-I. AHRQ Publication Number 11- E006. Rockville, MD: Agency for Healthcare Research and Quality, March 2011.