People with literacy challenges often hide in plain sight and may not be readily identifiable. In this article, Dr Michelle O’Driscoll and Prof. Laura J Sahm from the School of Pharmacy at University College Cork provide an overview on health literacy and its impact, in addition to how community pharmacy can support people with inadequate health literacy levels.
The recent IPU annual conference in April 2024 was a wonderful day of connection, discussion, and reflection. Community pharmacists from across the country gathered to learn about the exciting plans for the future of pharmacy and to debate the challenges and opportunities ahead for their profession. They were also asked to consider a holistic view of their own wellbeing, and the impact that their actions can have on the wellbeing and health outcomes of their patients.
As part of this dynamic programme, we were honoured to have the opportunity to present on the important topic of health literacy — what it means, how it affects patients, our practice, and our healthcare system. We gave examples of actionable ways in which we as pharmacists can support and empower those struggling with inadequate health literacy levels. People with literacy challenges often hide in plain sight and may not be readily identifiable. Indeed, this is exactly the intention as they do not wish to be seen as ‘other’ and have developed coping mechanisms, often over years, to disguise or compensate for this. The result is that they often do not benefit as fully as they could from the advice, counselling and general patient care available in the community pharmacy.
It was clear as the day progressed that this conversation had resonated, evidenced by the range of experiences shared with us afterwards that pharmacists themselves had encountered with patients: a woman not needing her Calcichew each month eventually revealing that she found them very uncomfortable to swallow; a gentleman who was using the Spiriva inhaler without piercing the capsule first; the litany of patients fleeing from Ukraine and other countries who could not read or understand English and yet needed to be communicated with; and the stories of those who when required to sign forms became distressed, had ‘forgotten their glasses’, or would manage no more than an X.
Health literacy is defined by the World Health Organisation as “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health”. More specifically, personal health literacy is “the degree to which individuals are able to find, understand and use information and services to inform health-related decisions and actions for themselves and others”. Important to note in these definitions is the shift to being “informed”, as opposed to a previous stance of health decisions being “appropriate”. More and more we are recognising patient autonomy, and their right to choose what is best or “appropriate” for them. Having adequate health literacy enables this decision process to occur based upon full individual understanding of all the information provided to them. Organisational health literacy refers to the degree to which organisations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. There is much that can be done to support our patients, from an organisational perspective, it’s just a matter of identifying what that might be in our respective settings and pharmacies.
To hear these stories directly from pharmacists and the frequency of these types of encounters, it’s apparent that they reflect the national statistics from the National Adult Literacy Agency (NALA):
These examples are also strikingly similar to the stories that we’ve encountered from those with lived experience, and from speaking with healthcare professionals across a breadth of sectors whilst taking part in health literacy education and reflecting on their practice.
“In terms of healthcare provision, being aware that time is precious and that it should be distributed equitably is important — not everybody will need ten minutes with you.”
We know that individuals with inadequate health literacy have poorer understanding of their treatments, lower adherence to their medications, and poorer overall health. They are less likely to avail of screening services, more likely to end up being hospitalised, and tend to present in later disease stages. A poorer understanding of risks and benefits, a reluctance to be seen to be failing to understand, and a fear of what they may encounter unaided when attempting to navigate the healthcare system, can leave people avoiding any interaction, and hence missing out on the benefits that healthcare could impart.
Health literacy is impacted by several factors including culture and education level, and these are things that as healthcare professionals we cannot change, but we can acknowledge. However, health literacy can also be impacted directly by the health system; how it’s set up, what assistance it offers, and how it supports people in understanding their diagnoses, treatments, and prognoses. This is where we as pharmacists can make a difference, where we can play a crucial role, as individual healthcare professionals, and through our organisational approaches. We can make changes in our setting that makes a real difference for people struggling with health literacy, and therefore with their healthcare.
We’re quite familiar with the concept of equality versus equity. Equality is giving everybody the same thing regardless. Equity is providing something relative to the need of the person, to give everybody a fair chance. In terms of healthcare provision, being aware that time is precious and that it should be distributed equitably is important — not everybody will need ten minutes with you. Some may need four, others may need fifteen. Some ‘red flags’ to consider when patients present that may help you to determine how best to distribute your time include: passing off the interaction to a spouse; refusing to fill out a form in front of you; forgetting their glasses; asking for information that is already clearly written; and not requesting medicines at the appropriate intervals each month.
With this in mind, we can strive to ensure that all interactions with our patients meet the Universal Precautions Approach — assuming that everybody does, or can have, some level of health literacy challenges. Tailoring our actions so that our baseline approach is health literacy friendly for all, will help to prevent anybody ‘falling through the cracks’ of the system. Above and beyond that, ensuring equitable use of time brings the service to the next level.
The types of actions that we can take can be categorised in the following way and are worth reflecting on from an individual and organisational perspective:
With all this food for thought, you may realise that you’re doing lots of things well in your practice to support health literacy, and yet could potentially further explore some other aspects to optimise patient care.
UCC host a CPD course on Health Literacy for Health and Social Care Settings, which is run by the School of Pharmacy. For more information go to ucc.ie/en/mh5001.
Highlighted Articles
