Health literacy in practice

Case scenario

You work part-time as a general practice pharmacist. You have completed the Org HLR for the practice and discovered that its current process for making appointments is confusing for the patients as their systems are partly electronic and partly in hard copy. Many patients are from a culturally and linguistically diverse background and don’t have digital devices. Access and navigation issues such as this are key health literacy challenges that patients encounter every day, these challenges may impact their ability to effectively manage their health.

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Introduction

Patients who lack sufficient ability to access, understand and evaluate health information to make appropriate health decisions (i.e. those with low health literacy), are at risk of poorer health in a variety of settings across the course of their life.

Health literacy is considered to be a significant social determinant of health that can influence an individual’s health outcomes. This combined with the recognition of the effect of social inequality on health-related outcomes has led to a move for targeted interventions to improve health literacy and therefore health outcomes.¹

Pharmacists on the front line are in the perfect position to improve health literacy and reduce health disparity in their community.

Populations at risk of poorer health outcomes

Patient groups recognised as being at highest risk of poor health outcomes and medicine-related harm include: those who have recently left hospital or had a change in living arrangements (such as moving in/out of aged care, respite care or location); Aboriginal and Torres Strait Islander people; those from culturally and linguistically diverse backgrounds; those living with disability; and those living with mental ill-health.²

These priority groups may require additional support from their pharmacist and pharmacy services. At a minimum pharmacists should endeavour to be health literacy responsive in order to reduce the risk of medicine-related harm and improve health outcomes.

Health literacy responsiveness is ‘the provision of services, programs and information in ways that promote equitable access and engagement, that meet the diverse health literacy needs and preferences of individuals, families and communities, and that support people to participate in decisions regarding their health and social wellbeing’.³

Recent discharge from hospital or relocation

Recent research highlights that an individual’s social context may be more predictive of potentially preventable hospital readmissions than their clinical factors.⁴ Furthermore, in this study the patients and their health professionals stated that health literacy was a major contributor to hospital readmission.^5,6

In addition to building health literacy capacity in communities, a primary care service known as ‘social prescribing’ has been implemented with good effect in the United Kingdom. Social prescribing links patients with non-medical needs to support sources provided by the community and volunteers to reduce isolation and support community connectedness. This initiative addresses the concern of social isolation⁷ and may support health literacy capacity building across whole communities. Whilst some GP practices are already offering this service, pharmacists who are well connected with their local community and the various services and programs available locally could consider their role and importance of ‘over the counter’ social prescribing in the future.

Aboriginal and Torres Strait Islander people

As outlined in the Closing the Gap report for 2020⁸, Aboriginal and Torres Strait Islander Australians continue to experience health inequities. Adhering to health literacy principles, it is important that pharmacists acknowledge the cultural preferences of individuals accessing health services. The endorsement of the Pharmaceutical Society of Australia’s (PSA) Reconciliation Action Plan highlights the commitment the profession has made to provide culturally safe health care through greater understanding and acceptance of the impact that generational disadvantage has had and continues to have on the mental and physical health of Aboriginal and Torres Strait Islander people. Understanding that health for some includes their cultural, spiritual, emotional, social, environmental, mental and physical health (prioritised in a variety of ways) also ensures that we, as pharmacists, are respectful of diversity in health preferences and differences in how individuals in their community may prioritise the elements of their health.

Culturally and linguistically diverse backgrounds

For many former refugees, health literacy will be impacted by unfamiliarity with health services, culturally unresponsive health service encounters, language barriers and the lifestyle and family upheavals associated with resettlement.^9,10 Former refugees may live in social environments (known as social contexts) where health-related decisions are not solely made by individuals. They are strongly influenced by family members, peers or community leaders. ^9,11 A Tasmanian study revealed that programs aiming to improve medication use of former refugee communities should not assume patients accessing pharmacy services are managing their illness individually. Therefore, where possible, their support people must be included.¹² Patient-centered labels have also been offered as a potential solution to support CALD communities with their medication.¹³ Further research is needed.

Living with a disability

Sahrai and Bittlingmayer¹⁴ have described disability as a poorly represented area. They outline the significant challenges associated with inclusion and health literacy and concluded that the design and administration of most health literacy measurement tools are not suitable to measure the health literacy level of people living with disabilities. This is a challenge, because the diversity in health literacy will be limited if it is only usable for people able to fill out a questionnaire. This issue also has significant implications for policymakers, as without appropriate advocacy, the voice of this priority population is unlikely to be heard. Continued advocacy of people with disabilities is required to ensure health systems respond to their needs and upholds their human rights. As described in the Introduction to Health Literacy article last month, distributive health literacy and health literacy responsiveness will be key to continuing to support people living with minor to severe disability so they can be active participants in their health.

Mental ill health

The community’s mental health literacy must become a focus for national policy and population monitoring so that the whole community is empowered to take action for better mental health.¹⁵

In contrast to people living with disability, since the mid-1990s there has been much greater focus on mental health literacy. Whilst deficiencies still exist, a range of interventions to improve mental health literacy have been developed.

Jorm¹⁵ distinguished a number of components of mental health literacy, including: knowledge of how to prevent mental disorders; recognition of when a disorder is developing; knowledge of help-seeking options and available treatments; knowledge of effective self-help strategies for milder problems; and first aid skills to support others who are developing a mental disorder or are in a mental health crisis.

Many of these initiatives have been developed with significant contributions from leading Australian pharmacists and successfully delivered in community pharmacy.^16-18

Management of health literacy

Pharmacists need to uphold their Competency Standards and the PSA Pharmacy Practice Standards (V5).¹⁹ As shown in Box 1, Standards 6.1, 6.2 (including 6.2.1, 6.2.2, 6.2.3, 6.2.4, 6.2.5) are specific to health literacy and were included for the first time in the 2017 PSA Practice Standards (V5).

Box 1: PSA Pharmacy Practice Standards (V5)¹⁹

Strategies and tools

Some useful strategies and tools have been developed to assist pharmacists to bring health literacy to the forefront of their healthcare and at every patient interaction. Here are a few to consider in your own practice.

Be polite and mind your language

Introduce yourself – The hellomynameis program was founded by the late Dr Kate Granger and her husband Chris in the UK’s National Health Service (NHS) in 2014. The program was initially an awareness campaign and employed social media strategies to raise awareness of four core values:

1. Communication
2. The little things matter
3. Person-centered care
4. Seeing me, and not just my disease/condition.

Importantly, these core values meaningfully and usefully intersect with health literacy principles, patient outcomes and the quality assurance of health services. In recognition of this, hellomynameis is now a Quality Indicator in many NHS hospitals. Pharmacists may like to consider how their staff and services uphold these core values and think about these each time they put their badge on in the morning.

Drop the jargon/health speak – In routine counselling pharmacists provide verbal and written information to support quality use of medicines (QUM) and optimal patient health outcomes. Recent media attention²⁰ now means that the term ‘counselling’ is better understood by the general public in Australia. Unfortunately, health literacy is still a less known and understood term. Pharmacists could help to change this by using each encounter with their patients to raise awareness of the importance of health literacy and offer health education specific to their patient’s medication and health needs with the goal of contributing to their health literacy and therefore self-sufficiency. An important role for pharmacists is to review the resources and written materials provided and consider alternative options most appropriate to the audience. Skilled in communication, pharmacists are well placed to determine the mode of delivery preferred by each patient (written, verbal, digital). There are many services and resources available to support health and community organisations to ensure their written resources are accessible for most. For example: https://26ten.tas.gov.au/PublishingImages/Tools/26TEN-Communicate-Clearly-A-Guide-to-Plain-English-Current-September-2014.PDF

Accept the challenge: become a health literacy responsive organisation

The Organisational Health Literacy Responsiveness (OrgHLR) self-assessment tool (discussed in the Introduction to Health Literacy article) includes six domains^16,21:

1. leadership and culture
2. systems, processes, and policies
3. access to services and programs
4. community engagement and partnerships
5. communication practices and standards
6. workforce.

October is health literacy month. During this month every year pharmacists could invite the pharmacy team to self-assess and discuss the health literacy responsiveness of their pharmacy. Based on findings, an action plan could be formulated. Having a health literacy responsiveness action plan is beneficial in identifying key areas for improvement in the pharmacy’s current practice. It also doubles as a patient-centred annual quality improvement activity that responds to the Australian Commission on Safety and Quality in Health Care’s National Statement on health literacy.²² Specifically, it ensures health literacy is embedded into the systems (organisational health literacy), ensuring effective communication and its integration into education for consumers and healthcare providers.

Once an action plan is in place, pharmacists could raise awareness and share achievements with others on social media (using the hashtag #OrgHLR_PSA, #responsive #health literacy).

Start with a CHAT

The Conversational Health Literacy Assessment Tool (CHAT) includes five themes and 10 questions (See Box 2).²³ CHAT is designed to support health professionals in starting a conversation with their patients. The tool is flexible, in that not all questions need to be used. Health professionals can select questions based on the situation and their clinical judgment. CHAT has been shown to increase awareness of health literacy and provide health professionals with a practical way of determining their patient’s health literacy needs.²⁴

Box 2: Conversational Health Literacy Assessment Tool (CHAT)

Start a MedsCheck with the Health Literacy Questionnaire (HLQ)

Pharmacists may already know which patients require additional support. This may be in the form of additional family/carer support (distributed health literacy), organisational health literacy responsiveness or the provision of education specific to the health literacy needs or a new health condition (e.g. newly diagnosed diabetes).

Consider the barriers and facilitators of each patient’s experience. Is their health literacy affecting their ability to use their medicines safely? Are you confident they understand the dosage instructions and the lifestyle advice you have just given them? Do you know if they are confident to ask you questions they may have about their health? Consider inviting those patients you are concerned about to complete the HLQ and share the results with you and their other healthcare providers. The HLQ is estimated to take between 7–30 minutes to complete.  For most 8 minutes is adequate time. The HLQ could be the perfect addition to your patient’s next MedsCheck.

As previously discussed, the HLQ consists of 44 questions and nine health literacy domains.²⁵

The domains cover:

1. feeling understood and supported by healthcare providers
2. having sufficient information to manage my health
3. actively managing my health
4. having social support for health
5. appraisal of health information
6. the ability to actively engage with healthcare providers
7. navigating the healthcare system
8. the ability to find good health information
9. understanding health information well enough to know what to do.

How to interpret your patient’s HLQ results

Data is collected for each item and domain based on the level of agreement with a set of health literacy statements (Domains 1-5) or the perceived difficulty of a health literacy characteristic (Domains 6–9). Domains 1–5 include a 4-point scale (4 – ‘strongly agree’, 3 – ‘agree’, 2 – ‘disagree’ or 1 – ‘strongly disagree’). Domains 6–9 include a 5-point scale (5 – ‘always easy’, 4-‘usually easy’, 3 – ‘sometimes difficult’, 2 – ‘usually difficult’ or 1 – ‘cannot do or always difficult’).

It is important to note that the HLQ was not designed to be a summed (to give a final score). Each domain result should be considered separately.

If a pharmacist is more concerned about a patient’s electronic health literacy, the eHLQ could be considered.²⁶ The eHLQ includes 7 domains and 30 questions. Domains include: use of technology to process health information; comprehension of health concepts and language; ability to actively engage with digital services; feeling safe and in control; motivation to engage with digital services; access to digital services that work; and digital services that suit individual needs.

Design principles for health literacy-friendly interventions

In addition to the above tools and strategies, Pharmacists may benefit for awareness of health literacy principles. Pharmacists should ensure their health promotion, health prevention or health education programs adhere to the Optimising Health Literacy and Access (OpHeLiA) principles.²⁷

The OpHeLiA principles are:

• outcomes focused – towards improved health and reduced health inequalities
• equity driven – where activities at all stages prioritise disadvantaged groups and those experiencing inequity in access and outcome
• a co-designed approach – where relevant stakeholders engage collaboratively in all activities at all stages to design solutions.
• a needs diagnostic approach – with participatory assessment of local needs using local data
• driven by local wisdom – where intervention development and implementation is grounded in local experience and expertise
• sustainable – optimal health literacy practice becomes normal practice and policy
• responsive – recognising that health literacy needs and appropriate responses vary across individuals, contexts, countries, cultures and time.
• systematically applied – a multi-level approach in which resources, interventions, research and policy are organised to optimise health literacy.

Key points

• People with low health literacy are at risk of poor health outcomes across a variety of situations and throughout their life.
• Pharmacists are well positioned in the community, and have access to strategies and tools, to help improve the health literacy of their patients.
• Pharmacists should tailor their services according to the health literacy needs and preferences of their patients.
• The Conversational Health Literacy Assessment Tool (CHAT) and Health Literacy Questionnaire (HLQ) can both be used to assess your patients’ health literacy.

Knowledge to practice

Pharmacists provide health advice and information to patients every day, and are in a prime position to respond to their patients’ health literacy needs and preferences. Involving the staff, pharmacists should consider reviewing their pharmacy’s health literacy responsiveness via a self-assessment tool (e.g. OrgHLR) and developing a health literacy action plan.

This October, consider taking the MedsCheck HLQ challenge to assess your patients’ health literacy and ensure their health literacy is front and centre in your service delivery in the future. In addition, consider where you could contribute to the health literacy of your local community. Finally, don’t make assumptions about the health literacy of your patients. Have a CHAT to ensure your services are supporting the safe use of medicines and optimal health outcomes for your local community. 

Case scenario (continued)

The practice held your suggested team meeting. The decision was to improve their current practice by standardising the digital appointment system using updated medical software and ask the patients to indicate their preferred method for receiving the information (appointment time and name of doctor).

The practice now keeps an embedded spreadsheet with the daily appointments to suit the practice. To be responsive to the needs of their patients, they offer all patients an electronic confirmation in addition to a hand-written appointment card with the time, name of the doctor and phone number to confirm or change the appointment. The team agrees to review the new system in one month to assess their satisfaction with the new system and also communicate with patients for their feedback.

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References

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DR ROSIE NASH BPharm (Hons), Grad Cert (Research), PhD, MPS, Senior Lecturer Public Health & Health Systems is a pharmacist and senior lecturer in public health specialising in health promotion interventions. She is Australia’s foremost researcher in children’s health literacy. She co-founded HealthLit4Kidsand established the cross-institutional Health Literacy & Equity Research Group. She has expertise in research and evaluation design, co-design and community-based research.