A national pharmacy strategy to help improve health literacy levels and promote pharmacists as health educators should be implemented, say Diarmuid Coughlan, a research pharmacist at the University of York, Stephen Byrne and Laura Sahm, pharmacy lecturers at University College Cork
The US Ask Me 3 programme encourages pharmacists to make patients aware of three key questions to ask (Partnership for Clear Health Communication at the National Patient Safety Foundation)
Its annual campaign to increase people’s involvement in decisions about their use of medicines now leaves a vacuum in the pharmacy strategy to promote patient empowerment.
This is a blow to pharmacy advocates of health literacy, at a time when the health literacy movement in the UK is gaining momentum.
One would think that all trained pharmacists and pharmacy staff can recognise patients who are struggling to cope with their medicines.
Moreover, according to the latest National Institute for Health and Clinical Excellence clinical guidance on medicines adherence, between 33 and 50 per cent of medicines prescribed for long-term conditions are not taken as recommended.1
Pharmacists are well positioned to recognise patients with adherence difficulties but what is the root of this problem? Is it a patient’s cognitive understanding of health-related materials and the greater healthcare environment?
The Wanless report of 2004 describes a “fully engaged scenario” that depends on patients being able to make informed decisions,2 and it is this concept that is the essence of any definition of health literacy. Safeer and Keenan describe health literacy as “the basic reading and numerical skills that allow a person to function in a health care environment”.3
Furthermore, Donald Nutbeam, former head of public health at the Department of Health, outlined a tripartite framework for health literacy that included three elements: functional, critical and interactive4 (see Continuing professional development article, pp333–6). Nutbeam’s framework shows levels of ability that patients may have.
But the concept of health literacy is expanding. In the past decade, interest and research in this field has gained momentum. Rima Rudd, director of society, human development and health at the Harvard School of Public Health, Boston, US, describes the growing and vibrant field that is health literacy by calculating the number of peer-reviewed publications concerned with its assessment, impact and development (see Panel).5
Prevalence of health literacy studies in peer reviewed medicine and public health journals |
|
Period |
Number of citations |
| 1960s | 6 |
| 1970s | 12 |
| 1980s | 35 |
| 1990s | 100 |
| 2000–05 | 800 |
| 2005–07 | 500 |
Low health literacy has economic implications at both an individual and societal level. In the US, it is estimated that low health literacy costs the economy $106 to $236bn (£71–158bn) annually.6
Furthermore, a conclusion from the 2006 Swiss Health Literacy Survey was that insufficient health literacy accounts for around 3 per cent of health spending or 1.5bn Swiss Francs (£850m).7
In the EU, 700,000 deaths per year and 33 million cases of ill health are attributed to inequality-related health conditions, and it is estimated that this accounts for 20 per cent of the total costs of health care and 15 per cent of the total cost of social security benefits.8
Although the causes of health inequalities are complex, low health literacy levels are clearly a contributing factor, as recognised in the 2008 World Health Organization “Closing the gap in a generation” report.9
The exact costs of poor health literacy to the UK Treasury are not known but it is reasonable to assume, based on European and US evidence, that the costs are significant.
Research in the UK
Most health literacy research has been carried out in North America but a few papers attempt to estimate the extent of low health literacy in the UK. A team from the Department of Epidemiology and Public Health, University College London, studied 759 adults using data collected by the British Market Research Bureau from participants’ homes around Great Britain.10
In this study, health literacy was assessed with a modified version of the “Test of functional health literacy in adults” tool. The paper concluded that around 11 per cent of adults in this British population survey have marginal or inadequate health literacy. That means one in 10 patients who walk through the pharmacy doors is not fully aware of the instructions or advice received from staff.
Researchers at London South Bank University (LSBU) used the “Rapid estimate of adult literacy in medicine” (REALM) tool on 300 coronary heart disease patients in hospital. This study shows a prevalence of low health literacy, as indicated by the REALM scores, of 19 per cent.11
In Scotland, Gordon et al used 127 consecutive rheumatoid arthritis patients attending a tertiary referral centre in Glasgow as their sample. They estimated that 15 per cent of their patients were “functionally illiterate” (ie, had problems with reading, writing, speaking and numeracy) and needed low-literacy health-related reading materials.12
Health literacy and pharmacy
In May 2008, a review published in the American Journal of Health-System Pharmacy by Victoria Tkacz et al entitled “Health literacy in pharmacy”, highlighted the paucity of research and data describing pharmacists’ knowledge and abilities in this area.13
In this review, the only research cited was a survey of community pharmacists’ ability to identify and assist low-literate patients with medicines use. The main finding was that only two pharmacies out of the 30 surveyed attempted to identify literacy-related needs among their customers. Unfortunately, neither pharmacy was asked or described how it did so.14
A strategy to improve health communication advocated by the National Patient Safety Foundation (NPSF) in the US has been the Ask Me 3 programme.15 This encourages pharmacists and other healthcare providers to make their patients aware of three key questions to ask:
1. What is my problem?
2. What do I need to do?
3. Why is it important for me to do this?
In an exploratory study in 2008, Miller et al evaluated the Ask Me 3 programme in US pharmacies. They concluded that the programme was a practical tool that creates awareness and reinforces principles of clear health communication and strives to improve health literacy.16
The 2005 Department of Health’s document “Choosing health through pharmacy” advocates the promotion of health literacy in community pharmacies: “Pharmacists and their staff can play an active part in the promotion of health literacy: by working with individual patients, and encouraging them to become advocates for service improvements; by working with other professionals to help them to explain to patients how to use their medicines effectively.”17
The Ask About Medicines campaign was an initiative that was similar in vein to the Ask Me 3 programme, where patients were encouraged to discuss their medicines with their pharmacist. In the absence of this campaign, there is no other initiative that encourages patients to discuss their medication or health issues with their pharmacists.
It may be that pharmacists will rely on medicines use reviews to assess, crudely, a patient’s health literacy level and respond accordingly.
The recent NICE guidance on medicines adherence is a step in the right direction but the real progress would be in developing a national pharmacy strategy effective in improving the health literacy levels of the British public.
Health literacy is a key component of the Department of Health (England) Health Inequalities Strategy. This document outlines the Government’s approach to hit the 2010 health inequalities public service agreement targets, assessing what has and has not worked, and setting the direction of travel beyond 2010.18
One of the successes has been the Skilled for Health programme. This is a partnership programme between the Department of Health, the Department for Education and Skills, and the charity ContinYou.
It combines learning objectives with health content to help adult learners gain a better understanding of their own health and how to make better use of the NHS, while improving their basic skills.
The future
Gill Rowlands, professor of primary care at LSBU is the lead of the UK Health Literacy Group. This is a group of over 200 health and education academics and practitioners, service providers and service users committed to raising the profile of health literacy as a remediable cause of health inequalities in England.
The aims of the group are to:
- Develop a critical mass of stakeholders
- Share skills, experience and ideas
- Develop the evidence base in health literacy in England
In February 2010, this group will be running a series of seminars in London with the objective of seeding discussion with a UK audience and producing a textbook. Pharmacists are involved and one of the areas of interest is health literacy and medicines.
In addition, Swiss researchers are moving towards developing an instrument that specifically measures competencies for health literacy. The Swiss Health Literacy Survey identified 30 core competencies for health relevant to all citizens, which are measurable.
This will now be applied and developed across other European countries through an EU-funded European Health Literacy Survey, hosted by Maastricht University.19
The fuss about health literacy could well be nothing new to the community pharmacist. One could be cynical and say that health literacy is just a fancy name for recognising patients’ abilities and and the remedy is to communicating clearly.
However, there is still much to be done to tackle this issue and empower more patients to be effective users of the healthcare system and the question for pharmacy is: what can we do?
ACKNOWLEDGEMENT We would like to thank Nicola Gray, lecturer in pharmacy Practice at the University of Nottingham, taking the time to review this article before publication.
References
1. National Institute for Health and Clinical Excellence. Clinical Guideline 76: Medicines adherence — quick reference sheet for pharmacists (accessed on 12 August 2009).
2. Wanless Report (2004) Securing good health for the whole population (accessed on 12 August 2009).
3. Safeer R, Keenan J. Health literacy: the gap between physicians and patients. American Family Physician 2005;72:387–8.
4. Nutbeam D. Health Literacy as a public goal: a challenge for contemporary health education and communication strategies into the 21st Century. Health Promotion International 2000;15:259–67.
5. Rudd R. Navigating complicated health systems. 6th International Research Conference Nottingham, UK, March 6–7, 2008. National Research and Development Centre for Adult Literacy and Numeracy: Moving in, on and up — social inclusion, persistence and progression (accessed 16 September 2009).
6. National Bureau of Economic Research. Low health literacy: implications for national health policy. 2007 (PDF 740K) (accessed on 14 September 2009).
7. Wang J, Schmid M. Regional differences in health literacy in Switzerland. Working paper of the Institute for Social and Preventative Medicine 2007, University of Zurich (accessed on 14 September 2009).
8. Farrell, C, McAvoy H, Wilde J. Tackling health inequalities — an all-Ireland approach to social determinants. Dublin: Combat Poverty Agency/Institute of Public Health in Ireland; 2008.
9. Commission on Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health (final report). Geneva: World Health Organization; 2008.
10. von Wagner C, Knight K, Steptoe A, Wardle J. Functional health literacy and health-promoting behaviour in a national sample of British adults. Journal of Epidemiology and Community Health 2007;61:1086–90.
11. Ibrahim S, Reid F, Shaw A, Rowlands G, Gomes G, Chesnokov, M et al. Validation of a health literacy screening tool (REALM) in a UK Population with coronary heart disease . Journal of Public Health 2008 (accessed on 16 September 2009).
12. Gordon M, Hampson R, Capell H, Madhok R. Illiteracy in rheumatoid arthritis patients as determined by the rapid estimate of adult literacy in medicine (REALM) score. Rheumatology 2002;41:750–4.
13. Tkacz VL, Metzger A. Pruchnicki ML. Health literacy in pharmacy. American Journal of Health-System Pharmacy 2008;65:974–81.
14. Praska JL, Kripalani S, Seright AL, Jacobsen TA. Identifying and assisting low-literacy patients with medication use: a survey of community pharmacies. Annals of Pharmacotherapy 2005;39:1441–5.
15. National Patient Safety Foundation. Ask me 3 (accessed on 28 December, 2008).
16. Miller MJ, Abrams M, McClintock B, Cantrell MA, Dossett CD, McCleeary EM et al. Promoting health communication between the community-dwelling well-elderly and pharmacists: the Ask Me 3 program. Journal of the American Pharmacists Association 2008;48:784–92.
17. Department of Health. Choosing health through pharmacy: a programme for pharmaceutical public health 2005–2015 (accessed on 12 August 2009).
18. Department of Health. Health inequalities: progress and next steps (accessed on 12 August 2009).
19. Maastricht University. The European Health Literacy Survey (accessed on 16 September 2009).
